Cerebrospinal Fluid (1,3)-βD-Glucan in Isolated Candida Meningitis TO THE EDITOR—We read with interest the publication by Litvintseva et al [1]
were all within normal limits. She was started on acetazolamide, and her headaches dramatically improved. Over the next year, she developed amenorrhea and difficulty walking, which precipitated re-presentation. She was never febrile. Her exam demonstrated only a mildly wide-based and unsteady gait. Mental status, cranial nerves, strength, sensation, and reflexes were all preserved. Urine human chorionic gonadotropin was undetectable and thyroid-stimulating hormone, follicle-stimulating hormone, and luteinizing hormone were all normal. Repeat MRI of the brain and spine showed enhancement of the basilar leptomeninges and extensive cauda equine involvement (Figure 1). Repeat lumbar puncture using a sterile lumbar puncture kit and glucan-free tubes showed an opening pressure of 16 cm water, 380 white blood cells/µL (50 cm water, 1330 white blood cells/µL (70% neutrophils), glucose of 26 mg/dL, and total protein of 100 mg/dL. Magnetic resonance imaging (MRI) of the brain and spine demonstrated basilar meningitis. CSF viral studies including cytomegalovirus polymerase chain reaction (PCR), herpes simplex virus PCR, and enterovirus PCR were all negative. Interferon-γ release assay, serum angiotensin-converting enzyme level, and CSF cryptococcal antigen
during the multistate outbreak of fungal meningitis and other infections. Clin Infect Dis 2014; 58:622–30. 2. Lyons JL, Roos KL, Marr KA, et al. Cerebrospinal fluid (1,3)-beta-D-glucan detection as an aid for diagnosis of iatrogenic fungal meningitis. J Clin Microbiol 2013; 51:1285–7. 3. Mikulska M, Furfaro E, Del Bono V, et al. (1–3)beta-D-glucan in cerebrospinal fluid is useful for the diagnosis of central nervous system fungal infections. Clin Infect Dis 2013; 56: 1511–2. 4. McGinnis MR. Detection of fungi in cerebrospinal fluid. Am J Med 1983; 75:129–38. Correspondence: Jennifer L. Lyons, MD, Division of Neurological Infections, Department of Neurology, Brigham and Women’s Hospital, 45 Francis St, Boston, MA 02115 (jlyons5@ partners.org). Clinical Infectious Diseases® 2015;60(1):161–2 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu737
Note Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Jennifer L. Lyons,1 Michael G. Erkkinen,1,2 and Ivana Vodopivec1,2 1 Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and 2Massachusetts General Hospital, Boston
References 1. Litvintseva AP, Lindsley MD, Gade L, et al. Utility of (1–3)-beta-D-glucan testing for diagnostics and monitoring response to treatment
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from blood and CSF were negative. Serum human immunodeficiency virus antibody was undetectable. Urine Blastomyces and Histoplasma antigens were negative. Serum and CSF BDG were 74 pg/mL and >500 pg/mL, respectively. Two weeks later, C. albicans grew from CSF culture. She was treated with oral fluconazole 400 mg/day, and at follow-up 2 months later reported return of her menses and improvement in her gait. Candida species can cause chronic meningitis in immunocompetent patients, but the diagnosis is difficult to make. CSF culture is insensitive [4], or Candida species can be a culture contaminant. CSF profiles and imaging do not well distinguish mycobacterial, autoimmune, or fungal etiologies, but treatment regimens are vastly different. A sensitive biomarker that points to fungal CNS infection early on could dramatically improve diagnostic capabilities of such infections and have therapeutic implications. Our finding of CSF BDG level greater than assay in the setting of subsequent positive serum BDG followed by positive CSF cultures for C. albicans suggests potential utility of this assay from CSF for Candida meningitis, especially as an early diagnostic adjunct. Further testing is required to determine cutoff and false-positive and -negative values in this population and to determine its utility in longitudinal utility.
were all within normal limits. She was started on acetazolamide, and her headaches dramatically improved. Over the next year, she developed amenorrhea and difficulty walking, which precipitated re-presentation. She was never febrile. Her exam demonstrated only a mildly wide-based and unsteady gait. Mental status, cranial nerves, strength, sensation, and reflexes were all preserved. Urine human chorionic gonadotropin was undetectable and thyroid-stimulating hormone, follicle-stimulating hormone, and luteinizing hormone were all normal. Repeat MRI of the brain and spine showed enhancement of the basilar leptomeninges and extensive cauda equine involvement (Figure 1). Repeat lumbar puncture using a sterile lumbar puncture kit and glucan-free tubes showed an opening pressure of 16 cm water, 380 white blood cells/µL (50 cm water, 1330 white blood cells/µL (70% neutrophils), glucose of 26 mg/dL, and total protein of 100 mg/dL. Magnetic resonance imaging (MRI) of the brain and spine demonstrated basilar meningitis. CSF viral studies including cytomegalovirus polymerase chain reaction (PCR), herpes simplex virus PCR, and enterovirus PCR were all negative. Interferon-γ release assay, serum angiotensin-converting enzyme level, and CSF cryptococcal antigen
during the multistate outbreak of fungal meningitis and other infections. Clin Infect Dis 2014; 58:622–30. 2. Lyons JL, Roos KL, Marr KA, et al. Cerebrospinal fluid (1,3)-beta-D-glucan detection as an aid for diagnosis of iatrogenic fungal meningitis. J Clin Microbiol 2013; 51:1285–7. 3. Mikulska M, Furfaro E, Del Bono V, et al. (1–3)beta-D-glucan in cerebrospinal fluid is useful for the diagnosis of central nervous system fungal infections. Clin Infect Dis 2013; 56: 1511–2. 4. McGinnis MR. Detection of fungi in cerebrospinal fluid. Am J Med 1983; 75:129–38. Correspondence: Jennifer L. Lyons, MD, Division of Neurological Infections, Department of Neurology, Brigham and Women’s Hospital, 45 Francis St, Boston, MA 02115 (jlyons5@ partners.org). Clinical Infectious Diseases® 2015;60(1):161–2 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/ciu737
Note Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Jennifer L. Lyons,1 Michael G. Erkkinen,1,2 and Ivana Vodopivec1,2 1 Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and 2Massachusetts General Hospital, Boston
References 1. Litvintseva AP, Lindsley MD, Gade L, et al. Utility of (1–3)-beta-D-glucan testing for diagnostics and monitoring response to treatment
162
•
CID 2015:60 (1 January)
•
CORRESPONDENCE
Downloaded from http://cid.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
from blood and CSF were negative. Serum human immunodeficiency virus antibody was undetectable. Urine Blastomyces and Histoplasma antigens were negative. Serum and CSF BDG were 74 pg/mL and >500 pg/mL, respectively. Two weeks later, C. albicans grew from CSF culture. She was treated with oral fluconazole 400 mg/day, and at follow-up 2 months later reported return of her menses and improvement in her gait. Candida species can cause chronic meningitis in immunocompetent patients, but the diagnosis is difficult to make. CSF culture is insensitive [4], or Candida species can be a culture contaminant. CSF profiles and imaging do not well distinguish mycobacterial, autoimmune, or fungal etiologies, but treatment regimens are vastly different. A sensitive biomarker that points to fungal CNS infection early on could dramatically improve diagnostic capabilities of such infections and have therapeutic implications. Our finding of CSF BDG level greater than assay in the setting of subsequent positive serum BDG followed by positive CSF cultures for C. albicans suggests potential utility of this assay from CSF for Candida meningitis, especially as an early diagnostic adjunct. Further testing is required to determine cutoff and false-positive and -negative values in this population and to determine its utility in longitudinal utility.
