CASE REPORT |
https://doi.org/10.5005/jp-journals-10081-1379 |
Case of Fatal Meningoencephalitis following Accidental Near Drowning
1-4Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
Corresponding Author: Vykuntaraju K Gowda, Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India, Phone: +91 9535212556, e-mail: drknvraju08@gmail.com
Received on: 16 October 2022; Accepted on: 25 November 2022; Published on: 30 June 2023
ABSTRACT
Introduction: Central Nervous System infections are the most common cause of mortality and morbidity in developing countries. We are reporting a rare case of neuroinfection following drowning.
Case description: Fourteen-year-old boy with a history of near drowning was initially treated for respiratory distress requiring mechanical ventilation and a right femur fracture. He was all right for 15 days at home later he developed a fever and weakness in his left lower and upper limbs. MRI of the brain showed a mass lesion with vasogenic edema requiring decompression craniotomy. Brain biopsy during decompressive craniectomy showed granulomatous inflammation composed of sheets of histiocytes, lymphocytes, and many foreign body giant cells. PAS and GMS stains highlight fungal hyphae/pseudohyphae.
Conclusion: Fungal meningoencephalitis should be considered in case of neuro infection following near drowning in addition to bacterial infections and should be treated urgently.
How to cite this article: Gowda VK, Kerur C, Patil A, et al. Case of Fatal Meningoencephalitis following Accidental Near Drowning. Pediatr Inf Dis 2023;5(2):56-57.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
Keywords: Fungal meningoencephalitis, Near drowning, Traumatic brain injury.
INTRODUCTION
Fungal infections of the central nervous system (FICNS) are potentially lethal conditions in children that can involve the meninges, brain, or spinal cord, and require a multidisciplinary plan of care to ensure proper treatment.1-3 FICNS are rare clinical entities, hence, we are reporting a rare case of FICNS following a near drowning.
CASE DESCRIPTION
A 14-year-old boy was normally presented with a fall from the tractor into muddy water following which he developed respiratory distress and a fracture of the right femur. He was treated in the local hospital with mechanical ventilation for 15 days and open reduction and internal fixation for fracture of the femur. He was all right for 15 days in the home following discharge, later he developed fever and weakness in his left lower and upper limbs. For that, he was readmitted to a local hospital where a computed tomography scan of the brain showed a mass with vasogenic edema requiring decompression craniotomy. Cerebrospinal fluid (CSF) analysis at the time of decompression showed increased cells (250 cells/µL 95% neutrophils, 5% lymphocytes), increased protein (250 mg/dL), and reduced glucose (25 mg/dL).
At admission, the child was hemodynamically stable, Glasgow Coma Scale of 5/15, and increased tone, with signs of meningeal irritations noted. Complete blood count showed neutrophilic leukocytosis, increased C-reactive protein, and normal liver and renal function tests. The treatment was continued with antibiotics. Histopathology slide was reviewed and was suggestive of granulomatous inflammation composed of sheets of histiocytes, lymphocytes, and many foreign body giant cells. Adjacent parenchyma shows perivascular inflammation infiltrates composed of lymphocytes, histocytes, and a few eosinophils. PAS and GMS stains highlight fungal hyphae/pseudohyphae (Fig. 1). We considered the possibility of tuberculosis (TB) of the brain, hence, work for TB was done. The CSF analysis was not suggestive of TB including cartridge-based nucleic acid amplification test (CBNAAT) and histopathology from the biopsy site does not show acid-fast bacilli. Hence TB of the brain was excluded. We also considered the possibility of vasculitis including neurosarcoidosis; however, the vasculitis workup was negative. The child was treated with amphotericin B, fluconazole, and flucytosine, and despite supportive care, the child expired. The immunodeficiency workup was negative.
Figs 1A and B: (A) Periodic acid–Schiff stain highlights fungal hyphae engulfed by giant cell; (B) Granulomatous inflammation with giant cell response
DISCUSSION
Neuro-infection can be due to a variety of organisms. FICNS are rare clinical entities and their development largely depends on the interplay between the host’s immune system and fungal virulence factors. Initially, we considered the possibility of bacterial infections due to drowning and skull injury. However, despite aggressive treatment with antibiotics no improvement was noted, hence, we considered the possibility of other infections. We also considered the possibility of TB of the brain; however, CSF analysis was not suggestive of TB, including CBNAAT, and histopathology from the biopsy site did not show acid-fast bacilli. Hence, TB of the brain was excluded. We also considered the possibility of nontubercular granulomatous disorders and excluded them as the vasculitis profile was negative. Based on the clinical scenario, no response to antibiotics and histopathological features of fungal infections of the brain were considered. Fungi may cause a variety of clinical syndromes, including meningitis, brain abscess, granuloma, and invasion of vasculature further complicating clinical presentation and treatment.4
Due to a growing number of organ transplants, chemotherapies, human immunodeficiency virus infections, congenital immunological deficiency, and medications such as corticosteroids the incidence of susceptible hosts is increasing. Infections can develop via hematogenous dissemination from a distant focus such as the lung, through direct implantation after trauma or secondary to the local extension from sinonasal, orbital, or spinal infections.5
Dissemination to the CNS by hematogenous spread or direct extension is the most serious and life-threatening complication of invasive fungal infection; associated mortality rates exceed 90%.6 Primary causative agents of FICNS are yeasts (Candida and Cryptococcus), molds (Aspergillus and Mucormycetes), and dimorphic fungi (Histoplasma, Blastomyces, and Coccidioides).7,11 Despite the aggressive nature of these infections, presenting symptoms can be subtle and nonspecific.
Since clinical manifestations of FICNS are subtle, an aggressive diagnostic approach and timely initiation of antifungal therapy are imperative to reduce morbidity and mortality.
CONCLUSION
Fungal infections of the central nervous system should be considered following near drowning in addition to children with immunodeficiency disorder as early treatment is important to prevent morbidity and mortality.
ORCID
Vykuntaraju K Gowda https://orcid.org/0000-0001-7244-0492
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