Unveiling the menace: a case series of fungal meningitis with galactomannan and beta-D-glucan detection and the efficacy of amphotericin B and flucytosine treatment

References

1. was done advised to send Free Light Chain Assay and Serum Protein Electrophoresis which were negative. Urine culture s/o E-coli so Antibiotics escalated to Inj.Meropenem 1 gm TDS. MRI Brain done on 2 nd day forgeneralized weakness and Drowsiness s/o Small patchy subacute-to-chronic infarct in the left occipital lobe in paramedian location. Few scattered foci of FLAIR hyperintensity in bilateral frontal deep white matter. Age related cerebral involution changes. HRCT Chest done on 2 nd day i/v/o Breathlessness s/o Trace to mild bilateral pleural effusion. Minimal interstitial edema in the bilateral lung parenchyma also observed as described. Patient had having intermittent fever spikes. In view of altered sensorium, CSF analysis was done on 4 th day, CSF routine was normal (Table 4). CSF Bacterial and fungal culture and BioFire came negative. While CSF fungal markers were revealed (Galactomannan and beta D-glucan positive) So IV amphotericin- B (Liposomal) and Tablet flucytosine 1000 mg twice a day was started. Serum fungal markers came negative. Blood c/s didn’t show any growth. Patient was kept on NIV in view of respiratory distress. Later on for worsening respiratory distress, severe tachypnoea, tachycardia, drowsiness, endotracheal intubation was done and patient was kept on Mechanical ventilatory support. Repeat blood c/s along with ET secretion c/s were sent for analysis, from which blood culture grew Gram positive bacterial growth, while ET secretion culture grew Klebsiella Pneumoniae bacterial growth, iv antibiotic was given according to culture and sensitivity. X-Pert Carba R Assay from ET culture revealed NDM and OXA-48 positive, anti-fungal (Injection + Tablet) were continued. Serum galactomannan came negative, while Beta-D-Glucan was still positive (334.87) so antifungal were continued. Cytomegalo virus DNA PCR was negative. Patient was gradually weaned off from ventilator. Patient had c/o oozing from CABG dressing site, pus swab c/s was sent for analysis, which grew Acinetobacter Baumannii bacterial, IV antibiotic was escalated according to sensitivity report. Patient was later on decannulated from tracheostomy as GCS was 15/15, ambulated and shifted out of ICU. Wound culture sent again on 30 th day of admission, culture reports on Staphyloccoccus hemolyticus so antibiotics were continued according to culture sensitivity. Sternal wire removal was done procedure remained uneventful, patient remained hemodynamically stable, afebrile, took orally well hence patient was discharged. Patient was hospitalized for nearly 35 days in hospital. Table 3: Blood investigations Day of admission Day 10 Day 20 Day 25 Day 30 Day of discharge Hb 11.3 10.9 11.1 9.9 10.3 10.6 WBC 10830 13130 15,490 15330 15850 12560 Platelet 142000 458000 391000 540000 452000 357000 Na 139 137 139 132 132 133 K 5 4.2 4.1 4.4 4 4.7 Cl 103 101 103 102 102 HCO3 19.8 28.3 27.7 22.2 22 Urea 103 113 118 S. Creat 2.64 2.38 2.6 2.1 2.51 2.61 CRP 123.2 69.48 56.6 39 91.8 56.90 PCT 2.92 8.7 1.1 1.46 S. galactomannan 0.95 0.32 0.46 S. beta-D-glucan 334.87 461.69 256 Blood Culture No growth Urine Culture E.coli CSF BioFire Not detected Hb: Hemoglobin; WBC: White blood cells; CRP: C-reactive protein; PCT: Procalcitonin; CSF: Cerebrospinal fluid Table 4: CSF investigations CSF Cell count Differential count Protein CSF glucose Chloride LDH Matching glucose Galactomannon Beta-D- glucan Sample 1 <10 61 56 120 41 108 3.82 165.52 Sample 2 <5 63 60 113 59 107 0.42 13.43 426 Patel et al. / Indian Journal of Microbiology Research 2025;12(3):423–428
2. Case 3 A male of 79 years presented with complaints of altered mental status and drowsiness without any co-morbidities. He had history of recent hospitalization within 90 days for circumcision and chikungunya fever. Patient was admitted in ward and shifted to ICU in view of hypotension and hypoxia. After sending blood investigations (Table 5), blood culture and urine culture BL-BLI was started. On arrival to ICU GCS- E2 V2 M5, pupils were bilaterally equal and reacting to light, no focal neurological deficit, no signs of meningeal irritation. In view of persistent fever and patient not improving, CT scan from head to pelvis was done, which showed no abnormalities. Neuro-physician opinion was taken and CSF was planned and done for diagnostic purpose. ANA and ANCA negative. MRI brain with contrast enhanced venography was done revealed no acute findings and brain parenchymal abnormalities seen. Fungal marker in the form of galactomannan and Beta-D-Glucan were sent and turned to be positive. Meanwhile patient was intubated and ventilated in view of GCS<7 and hypotension. Injectable amphotericin 3 out mg/kg and flucytosine 100 mg/kg/day were started and given for 28 days. After 3-5 days of starting amphotericin and flucytosine patient neurologically improved GCS – 8/10 E-3 V-T and M-5 without any focal neurological deficit. Voriconazole was given for 14 days, after 1 month Decannulation was done. Patient was discharged after approximate 50 days of admission.
3. Discussion Humans inhale numerous fungal spores daily, most of which are cleared by alveolar macrophages and neutrophils within the respiratory tract. Among pathogenic fungi, Aspergillus fumigatus and Aspergillus flavus are the most common species associated with invasive infections, though other species have been reported to cause CNS disease. Fungal meningitis presents significant challenges in critical care because of its nonspecific symptoms, diagnostic limitations, and restricted therapeutic options. This series emphasizes the importance of early recognition, rapid diagnostic evaluation, appropriate antifungal therapy, and careful monitoring to optimize patient outcomes. Our findings highlight the need for heightened awareness among healthcare professionals and better access to advanced diagnostic tools. The conventional diagnostic modalities for CNS fungal infections often have limited sensitivity, making diagnosis difficult. In this context, CSF biomarkers such as galactomannan and beta-D-glucan serve as valuable adjuncts, enabling earlier identification of fungal pathogens. In one study, the combined sensitivity and specificity of these biomarkers exceeded 85% for detecting CNS fungal infections. Although fungal meningitis is more common in immunocompromised patients, it may also occur in immunocompetent individuals, as observed in our series and in earlier reports by Elsawy et al. 1 and Pettit et al. 2 Table 5: Blood and CSF investigations Day of admission Day 10 Day 20 Day 25 Day 30 Day of discharge Hb 9.4 11.9 8.9 9.5 10.2 9.6 WBC 10,500 10,370 10,640 13,600 8110 9570 Platelet 367000 2,05,000 3,14,000 118000 2,85,000 261000 Na 120 132 131 129 141 131 K 3.7 3.2 3.9 4.7 4.5 4.8 Cl 83 105 104 94 107 89 HCO3 26.6 25.2 21.7 25.2 26 29 Urea 13 17 80 91 33 S. Creat 0.7 1.3 1.26 1.35 1 1.02 CRP 178 133 81 12.2 37 15.6 PCT 78.33 2.49 0.52 1.38 - - S. galactomannan - 1.05 1.17 - 0.48 - S. beta-D-glucan - >523.43 129.24 - 59.60 - Blood culture - - - - - - Urine culture - - - - - - CSF BioFire - - - - - - Hb: Hemoglobin; WBC: White blood cell count; Na: Sodium; K: Potassium; Cl: Chloride; HCO₃⁻ = Bicarbonate; CRP: C- reactive protein; PCT: Procalcitonin; CSF: Cerebrospinal fluid. Table 6: CSF investigations CSF Cell count Differential count Protein CSF glucose Chloride LDH Matching glucose Galactomannon Beta- D- glucan Sample 1 10 L-100% 60 46 116 24 212 6.03 155 Patel et al. / Indian Journal of Microbiology Research 2025;12(3):423–428 427 Similar to our findings, Chong et al. have shown that CSF galactomannan and beta-D-glucan are useful in diagnosing fungal meningitis. 3,4 A high index of suspicion is crucial for detecting such infections, as emphasized by Rathish et al. 5 and Desai et al. 6 unlike our cases, Hiraga et al. reported successful treatment with voriconazole and corticosteroids, with diagnosis established by CSF galactomannan. 7 Forster et al. further demonstrated that combining galactomannan with beta-1, 3-D-glucan improved the diagnostic yield compared to either marker alone. 8 As described by Tang et al., fungal meningitis remains a life-threatening condition in which early diagnosis and prompt initiation of antifungal therapy are essential for survival. 9 Memória et al. reported successful treatment with liposomal amphotericin B and itraconazole, a therapeutic approach similar to ours. 10 Shariati et al. and Walsh et al. have also advocated for early diagnosis and antifungal treatment in CNS aspergillosis. 11,12 In one comparative study, liposomal amphotericin B plus flucytosine demonstrated superior efficacy and fewer adverse effects compared to voriconazole, supporting our choice of induction therapy in these cases. This aligns with findings from Schwartz et al. who reported improved survival rates when combination therapy was initiated early in invasive CNS aspergillosis. 13 Kourkoumpetis et al. highlighted that delayed antifungal treatment was associated with a twofold increase in mortality among CNS fungal infection cases. 14 Moreover, Perfect et al. in the updated IDSA guidelines reinforce the integration of biomarker-based diagnosis and early combination antifungal therapy for optimal outcomes. 15 However, as this series is retrospective and involves a small number of patients, the results cannot be generalized, and larger prospective studies are needed.
4. Conclusion Biomarker in the form of CSF galactomannon and Beta-D- glucan facilitated early diagnosis of fungal infection. We also revealed that in such cases usage of liposomal amphotericin with flucytosine can be very useful for treatment without major adverse drug reactions.
5. Clinical Significance This case series underscores the diagnostic utility of CSF galactomannan and beta-D-glucan assays in the early identification of fungal meningitis, particularly when conventional CSF studies and cultures are negative. By facilitating rapid diagnosis, these biomarkers allow for prompt initiation of targeted antifungal therapy, which is critical for improving survival and neurological outcomes. In our experience, the combination of liposomal amphotericin B and flucytosine, followed by voriconazole as consolidation therapy, proved effective and was well tolerated, aligning with current Infectious Diseases Society of America (IDSA) recommendations. Early diagnosis and treatment not only improve prognosis but can also reduce the duration of ICU and hospital stay, thereby minimizing healthcare costs and complications. Previous studies have demonstrated that early initiation of combination antifungal therapy significantly improves survival in CNS aspergillosis and that delayed treatment is associated with markedly higher mortality. Therefore, incorporating CSF fungal biomarker testing into routine workup for patients with unexplained meningoencephalitis could transform clinical practice by enabling faster, evidence-based therapeutic decisions.
6. Ethical Approval This study was approved by Institutional ethical approval with ref. no. SVIEC/on/Medi/RP/June/25/72.
7. Source of Funding None.
8. Conflict of Interest None. References
9. Elsawy A, Almaghrabi R, Elsaid T, Alshehri M, Almaghrabi A. Aspergillus terreus meningitis in immunocompetent patient: a case report. Front Microbiol. 2015;6:1353.
10. Pettit AC, Kropski JA, Castilho JL, Schmitz JE, Rauch CA, Mobley BC, et al. The index case for the fungal meningitis outbreak in the United States. N Engl J Med. 2012;367(22):2119–25.
11. Chong GM, Maertens JA, Lagrou K, Driessen GJ, Cornelissen JJ, Rijnders BJ. Diagnostic performance of galactomannan antigen testing in cerebrospinal fluid. J Clin Microbiol. 2016;54(2):428–31.
12. Malani AN, Singal B, Al Sous O, Summons TA, Durkin MM, Pettit AC. (1,3)-β-d-glucan in cerebrospinal fluid for diagnosis of fungal meningitis associated with contaminated methylprednisolone injections. J Clin Microbiol. 2015;53(3):799–803.
13. Rathish B, Wilson A, Warrier A, Pillay R, Thomas J. Aspergillus fumigatus meningitis in an immunocompetent young woman. Indian J Pathol Microbiol. 2020;63(3):488–90.
14. Desai SD, Seth S, Shah A, Vaishnav B. Aspergillus meningoencephalitis in a patient with human immunodeficiency virus infection: normal cerebrospinal fluid does not mean absence of meningitis. Indian J Sex Transm Dis AIDS. 2016;37(2):185–9.
15. Hiraga A, Aoki R, Nakamura KI, Kuwabara S. Rapidly progressive Aspergillus meningitis successfully treated with voriconazole and corticosteroids. Neurol Sci. 2018;39:577–9.
16. Forster J, Hoenigl M, Suerbaum S, Wagener J, Dichtl K. Serologic biomarkers in Candida and Aspergillus infections of the central nervous system: A comparison of galactomannan, mannan and β- 1,3-D-gucan testing from serum and cerebrospinal fluid. Mycoses. 2022;65(7):709–14.
17. Tang HJ, Liu WL, Chang TC, Li MC, Ko WC, Wu CJ, et al. Multiple brain abscesses due to Aspergillus fumigatus in a patient with liver cirrhosis: a case report. Medicine (Baltimore). 2016;95(9):e2813.
18. Memória Jr JR, Lopes Rufino EP, do Rêgo Aquino PL, Vaz Guimarães Filho F, Maranhão Neto T, de Vasconcelos HKNB. Brain aspergilloma in an immunocompetent individual: a case report. Surg Neurol Int. 2020;11:211.
19. Shariati A, Didehdar M, Rajaeih S, Moradabadi A, Ghorbani M, Falahati V, et al. Aspergillosis of central nervous system in patients with leukemia and stem cell transplantation: a systematic review of case reports. Ann Clin Microbiol Antimicrob. 2021;20(1):44. 428 Patel et al. / Indian Journal of Microbiology Research 2025;12(3):423–428
20. Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, et al.; Infectious Diseases Society of America. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008;46(3):327–60.
21. Schwartz S, Ruhnke M, Ribaud P, Corey L, Driscoll T, Cornely OA, et al. Improved outcome in central nervous system aspergillosis, using voriconazole treatment. Blood. 2005;106(8):2641–5.
22. Kourkoumpetis TK, Desalermos A, Muhammed M, Mylonakis E. Central nervous system aspergillosis: a series of 14 cases from a general hospital and review of 123 cases from the literature. Medicine (Baltimore). 2012;91(6):328–36.
23. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of America. Clin Infect Dis. 2010;50(3):291–322. Cite this article: Patel R, Patel BB, Jansari T, Chauhan AP, Javadekar T. Unveiling the menace: a case series of fungal meningitis with galactomannan and beta-D-glucan detection and the efficacy of amphotericin B and flucytosine treatment. Indian J Microbiol Res. 2025;12(3):423–428.