2000 Associates' Presentations
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The Case of the Missing Immunocompromise
Beverly Ness, MD & Theresa Seville, MD, Medical College of Wisconsin, Milwaukee, WI
Candida, while the fourth most common cause of blood stream infection, is an uncommon cause of CNS infection and rarely develops in healthy adults. Presented is the case of a 64-year-old female who was diagnosed with candidal CNS infection. She had been in her usual state of health up until three weeks prior to admission when she developed a headache and flu-like symptoms. This progressed to mental status changes and eventually coma. CSF analysis showed a pleocytosis with lymphocytic predominance, normal glucose and elevated protein. A gram stain did not reveal any organisms. A contrast MRI of the brain revealed numerous punctate enhancing lesions involving the white matter of cerebral hemispheres, the pons, and midbrain. An open brain biopsy revealed multiple granuloma/microabcess formation. A Gomorimethenamine silver stain confirmed the presence of yeast and pseudohyphal forms, consistent with Candida species. Blood, CSF and brain tissue cultures failed to grow organisms. A search for the source of candidemia was non-revealing: TTE, TEE, CT scans of the abdomen and pelvis were negative. This patient was treated with a prolonged course of IV amphotericin B alone, as she developed markedly elevated transaminases while on flucytosine. Her condition progressively improved and at time of discharge, three months after admission, was able to perform activities of daily living and walk 180 feet with minimal assistance. She is currently continuing therapy with fluconazole. This case is unusual, as the patient does not have any of the known risk factors for candidal CNS infection. Prompt diagnosis and initiation of therapy resulted in a good outcome in this patient who had potentially disabling and life-threatening illness.
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