Background and Importance Amphotericin B (AmB) is a standard treatment for opportunistic fungal pathogens such as cryptococcal meningitis. Its toxicity has been reduced by using lipid formulations of Amb (L-AmB), allowing the administration of higher doses. However, AmB shows slow and poor penetration to the cerebrospinal fluid (CSF) when administered by intravenous injection. To achieve higher concentration in CSF, intrathecal administration of L-AmB has been successfully used. Appearance of different Candida species in CSF are infrequent but critical. There are still significant knowledge gaps in pharmacodynamics and pharmacokinetics as the experience of central nervous system (CNS) Candida infections treated with L-AmB intrathecal literature is limited to one case report.
Aim and Objectives To describe the use of intrathecal L-AmB in Candida meningitis in one patient.
Material and Methods A 59-year-old woman with a history of obesity with metabolic syndrome was admitted to the Neurosurgery Service for bilateral cerebellar ischemic infarction needing decompressive craniectomy. During her evolution she presented as a complication CSF fistula requiring lumbar draining of CSF and subsequent urgent surgical intervention. CSF analysis revealed leukocytes 1398/mm3, 6.38 mg/dL of glucose and 315 mg/dL of protein. C. albicans and Nakaseomyces glabrata (previously named C. glabrata) were isolated in removed adipose flap and CSF, respectively. Intravenous and intrathecal antifungal therapy was required and so, the Pharmacy Service was asked to develop a L-AmB intrathecal injection.
Results Treatment with intravenous L-AmB (5 mg/kg/day) and oral flucytosine (25 mg/kg/6 hours) were initiated. After ten days, due to the inability of removing the lumbar drain and the persistence of CNS infection, L-AmB intrathecal was added (0.5 mg/day, dissolved in 3 mL of 5% dextrose). Given the good evolution, it was proposed to de-escalate to voriconazole, flucytosine and intrathecal L-AmB. Intrathecal L-AmB was discontinued at the 20th day of treatment when the CSF cell count, glucose and protein levels returned to normal levels and the last four CSF cultures kept sterile. L-AmB treatment was well tolerated, and no side effects were observed.
Conclusion and Relevance Despite the limitations in the interpretation of this case report, the administration of intrathecal L-AmB may constitute a less toxic therapeutic alternative to conventional AmB (deoxycholate) for Candida meningitis.
References and/or Acknowledgements 1. DOI: 10.1155/2015/340725.
Conflict of Interest No conflict of interest