Cerebrospinal Fluid (1,3)- -D-Glucan in Isolated Candida Meningitis

To the Editor—We read with interest the publication by Litvintseva et al [1] regarding evaluation of (1,3)-β-d-glucan (BDG) in cerebrospinal fluid (CSF) of patients with Exserohilum central nervous system (CNS) infections (also reported by Lyons et al [2]) and, more recently, the letter by Mikulska et al [3] regarding this marker in invasive Aspergillus, Cryptococcus, and histoplasmosis. We report the first case of its detection in a patient with Candida albicans meningitis. A 31-year-old woman with a history of intravenous drug use presented for headaches that had started 1 year prior, at which time lumbar puncture showed an opening pressure of >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 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% neutrophils), glucose of 39 (serum of 100) mg/dL, and protein of 222 mg/dL. CSF Venereal Disease Research Laboratory and cryptococcal antigen tests were negative. Galactomannan 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.