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NEURORADIOLOGY Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 711-713
Neonatal candida infection of the CNS : A case report


Department Of Radiodiagnosis, Maulana Azad Medical College And Associated Lok Nayak Hospital, Jawahar Lal Nehru Marg, New Delhi-110002, India

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Date of Submission15-Oct-2006
Date of Acceptance20-Nov-2006
 

Keywords: Candidiasis, Neonates, CNS

How to cite this article:
Singh S, Chowdhury V, Dixit R, Prakash A. Neonatal candida infection of the CNS : A case report. Indian J Radiol Imaging 2006;16:711-3

How to cite this URL:
Singh S, Chowdhury V, Dixit R, Prakash A. Neonatal candida infection of the CNS : A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Dec 3];16:711-3. Available from: https://www.ijri.org/text.asp?2006/16/4/711/32329

   Introduction Top


Fungal infections are uncommon in children and their manifestations in children are identical to those in adults. These infections can result in chronic meningitis or abscesses. Candida albicans may cause a disseminated fungal infection, particularly in patients with congenital anomalies. The CNS is involved in two third of cases of systemic candidiasis in premature infants.


   Case Report Top


A 20 day old neonate developed high grade fever and septicemia. He was born preterm and had a birth weight of 1.5 kg. Two sets of blood cultures (the blood was drawn on 2 consecutive days) yielded Candida albicans. Urine culture also yielded Candida albicans. The neonate was referred for MR examination to rule out CNS involvement. Axial T1W MR images [Figure - 1] revealed round focal areas of signal alteration within the parenchyma isointense to the gray matter. FLAIR coronal MR images [Figure - 2] revealed signal suppression of the focal lesions suggesting cystic nature of the lesions. Postgadolinium T1W axial [Figure - 3]a, b revealed ring enhancement of the lesions. Postgadolinium T1W coronal MR images [Figure - 4]a, b also revealed enhancement of the lesions which were seen in both the cerebral hemispheres. Based on these MRI findings a diagnosis of Candidal microabscesses was considered. A lumbar puncture performed revealed Candida fungal element in the CSF confirming the diagnosis.


   Discussion Top


Candida are present as yeast forms with reproduction resulting from budding and the formation of pseudohyphae which are smaller than the hyphal forms. Candida is present as part of the normal intestinal flora. Superinfection from Candida results from disturbances in the equilibrium that normally exists within the intestinal flora, usually resulting from chemotherapy, antibiotic therapy and hematologic abnormalities such as thrombocytopenia. Because of superinfection, hematogenous dissemination may result. In patients with disseminated Candida, the most common organ involved is the kidneys with the brain being the second most common organ involved [1]. Other portals of entry include indwelling catheters or from intravenous drug abuse with resulting candidal endocarditis [2],[3] .Of patients with candidal endocarditis, 80% also have CNS candidiasis.

The frequency of CNS involvement in the setting of disseminated disease is approximately 50% [3]. The CNS is involved in two thirds of cases of systemic candidiasis in premature infants. In these cases, the entire CNS is involved in a diffuse cerebritis with the formation of multifocal microabscesses without any areas of predilection [4]. Candida infections may also result in abscess formation. The abscesses have a similar appearance to bacterial abscesses except that the walls tend to be thicker. Candida meningitis may also occur and it tends to resemble other granulomatous meningitis with involvement of the basal cisterns [4].

Intraparenchymal haemorrhage and thrombosis with secondary infarction have also been described as consequences of cerebral candidiasis as well as a vasculitis similar to that induced by aspergillosis [5]. Invasion of the blood vessel walls by the fungus is the possible initiating event. The source of fungi is believed to be septic emboli. Rarely, these emboli invade the vascular wall instead of producing vascular occlusion and a mycotic aneurysm results [6],[7].

Neuropathologic lesions in cerebral candidiasis [2]

Meningitis, ependymitis Microabscesses, macroabscesses produced by noncaseating granulomata and diffuse glial nodules.

Thrombosis, secondary infarction.

Vasculitis from invasion of vessel wall.

Mycotic aneurysm, fungus ball

Haemorrhage or haemorrhagic necrosis ,demyelination and transverse myelitis.

On CT scan the microabscesses and granulomas typically show enhancement. On MR imaging, a hypointense to isointense signal of the fungal granuloma on T2W MR images has been suggested [8]. A target appearance has also been described on which T2 weighted images show a well-delineated hypointense area surrounded by a hyperintense rim.

It could be argued that the drug treatment for systemic and cerebral candidiasis is the same, thus diagnosis of one or the other is sufficient to warrant therapy. On the contrary, cerebral candidiasis may warrant a different therapy. For example, a large candidal abscess may require neurosurgical intervention as well as drug therapy. A mycotic aneurysm may result in subarachnoid haemorrhage and demands a thorough investigation of the heart valves. Also, it is necessary to monitor the extent and location of the infection. Thus, it is important to have an early diagnosis of both systemic and central nervous system candidiasis for efficacious treatment [2].

 
   References Top

1.Salaki JS, Louria DB, Chmel H. Fungal and yeast infections of the central nervous system. Medicine 1984; 63: 108-132.  Back to cited text no. 1  [PUBMED]  
2.Lipton SA, Hickey WF, Morris JH, et al. Candidal infection in the central nervous system. Am J Med 1984; 76: 101-108.  Back to cited text no. 2    
3.Burgert SJ, Classen DC, Burkei JP, Blatter D. Candidal brain abscess associated with vascular invasion : a devastating complication of vascular catheter related candidemia. Clinical Infectious Diseases 1995; 21: 202-205.  Back to cited text no. 3    
4.Ressler JA, Nelson M. Central nervous system infections in the pediatric population. Neuroimaging Clinics of North America 2000; 10(2): 427-443.  Back to cited text no. 4    
5.Myerwitz RL, Pazin GJ, Allen CM : Disseminated candidiasis. Changes in incidence, underlying diseases and pathology. Am J Clin Pathol 1977; 68: 29-38.  Back to cited text no. 5    
6.Molinari GF, Smith L, Goldstein MN et al: Pathogenesis of cerebral mycotic aneurysms. Neurology 1973; 23: 325-332.  Back to cited text no. 6    
7.Stehbens WE. Ultrastructure of aneurysms. Arch Neurol 1975; 32: 798-807.  Back to cited text no. 7  [PUBMED]  
8.Go JL, Kim PE, Ahmadi J, Segall H, Zee CS. Fungal infections of the central nervous system. Neuroimaging clinics of North America 2000; 10(2): 409-425.  Back to cited text no. 8    

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Correspondence Address:
S Singh
212, Sfs Flats, Phase Iv, Ashok Vihar, Delhi - 110052
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32329

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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[Pubmed]



 

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    Introduction
    Case Report
    Discussion
    References
    Article Figures

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