Hematologic candidal menigoencephalitis is a serious condition with associated severe morbidity and

1
Hematogenous Candidal Meningoencephalitis1948-200
9 Cohort
Bonifant, CL1 Petratiene, R2 North, P2 Walsh,
T2
1Georgetown University School of Medicine,
Washington, DC 2Pediatric Oncology Branch,
National Institutes of Health, Bethesda, MD
Abstract
Results
Hematogenous candidal meningoencephalitis (HCME)
is a fungal infection of the CNS occurring
primarily in immunocompromised hosts. The
comorbidities that lead to increased
susceptibility for this serious condition also
contribute to poor outcomes. Additionally,
diagnostic delay caused by nonspecific
symptomatic presentation, nondiagnostic
biomarkers and laboratory signs, vague
neuroradiological signs, and underappreciation of
the disease are common. As a significant cohort
of patients are neonates, years of life lost
secondary to high HCME morbidity and mortality
are remarkable. Treatment since first diagnosis
is likely improving, as percent mortality is
decreasing even while incidence is increasing.
Our objectives in this study were to enhance
understanding of the epidemiology, clinical
characteristics, neuroradiological
manifestations, treatment strategies, and outcome
of HCME, in order to improve diagnostic
capability and ultimately, to decrease overall
disease burden in the general population.
Figure 2. Systemic locations of HMCE involvement
Table 2 Risk factors for candidal infection and
associated mortality
Table 1 Demographic characteristics and
associated mortality of patient group
Figure 1. Clinical manifestations of HCME
presented as percent of finding within the given
age group
Table 3. Laboratory results
Figure 4. Common neuroradiological abnormalities,
by diagnostic method
Figure 3. HCME CNS involvement and associated
mortality
Figure 5. Candidal species causing HCME
Figure 6. Number of cases and percent mortality,
over time
Table 4. Antifungal treatment administered
Discussion
We undertook this review as an analysis of HCME
cases with an intent to contribute to
improvements in diagnosis and treatment of this
poorly recognized disease. We found, as expected,
that neonates made up a significant proportion of
all cases. Unexpectedly, other concurrent
conditions were less clearly relevant. Access of
Candida to the bloodstream seemed the most
important risk factor shared by patient groups.
Diagnostic capability is clearly lacking, though
this review does not uncover any easy method for
improved sensitivity or specificity of diagnosis.
Interestingly, C. albicans was the most
frequently observed candidal species in this
cohort, likely due to both its prevalence and
pathogenicity. We believe that the increases in
case numbers parallels greater recognition as
well as enlarging susceptible patient
populations. Treatment has improved over time,
evident by the decreased mortality per decade.
Conclusions
Methods
Hematologic candidal menigoencephalitis is a
serious condition with associated severe
morbidity and mortality, especially in the naïve
neonatal population. Improved diagnostic
capability as well as novel and superior
treatment options have the potential to
significantly impact the outcome of this grave
disease.
Case studies were initially identified by a
robust MEDLINE literature search with pertinent
keywords. Individual references in each article
were reviewed for identification of additional
case reports. Inclusion of each report was made
on the basiss of selected criteria documentation
of infection, therapeutic intervention,
antifungal therapy, and outcome, with attribution
of cause of death made by the author of each case
report. Microsoft Excel for Mac, version 11.5.1
was used for database construction and
management. Data were expressed as means /-
standard error of the mean.