Diagnostic Dilemma of Aspergillus Meningitis in Patients With Hepatitis C Virus Co-Infection: A Case Series

Abstract

Aspergillus meningitis can occur in immunocompromised and immunocompetent patients. The diagnostic yield is only 39% in immunocompromised patients and 69% in immunocompetent patients. Diagnosis can be challenging, as repeated cerebrospinal fluid (CSF) cultures can be negative. Even with multiple cultures, the diagnostic yield is meager, sometimes requiring a tissue diagnosis. However, prompt recognition and treatment initiation are crucial to minimize morbidity. We present two cases of patients with a history of intravenous drug use disorder (IVDU) co-infected with hepatitis C virus (HCV) and Aspergillus. Two young Caucasian patients with untreated HCV infection and a history of IVDU, presented with fevers and headaches. Their imaging and multiple CSF samples showing pleocytosis with negative fungal cultures led to a diagnostic dilemma. Due to progressive decline and to ascertain a definitive diagnosis, a brain biopsy resulted in a tissue diagnosis of fungal meningitis secondary to Aspergillus, with hyphae and granulomas, in both individuals. In the workup of chronic meningitis, Aspergillus infection should be strongly considered in patients with IVDU and HCV co-infection. In patients with chronic meningitis lacking definitive diagnosis from spinal fluid, tissue sampling should be pursued as soon as possible to ensure rapid treatment and prevent disability. HCV is associated with a reduction in cellular immunity; our two cases support that HCV and a history of IVDU carry risks of immunosuppression, warranting early and expedited workup for chronic fungal meningitis.

J Neurol Res. 2022;12(1):25-29
doi: https://doi.org/10.14740/jnr706