title: Candida meningitis post Gliadel wafer placement successfully treated with intrathecal and intravenous amphotericin B.
abstract: OBJECTIVE
  To report a case of Candida meningitis post Gliadel wafer (polifeprosan 20 with carmustine implant) placement successfully treated with the combination of intrathecal and intravenous amphotericin B.
  
  
  METHODS
  A 33-year-old white female with a history of recurrent oligodendroglioma was admitted to the neuroscience intensive care unit with acute mental status changes. Computed tomography of the head demonstrated a cystic dilation of the right frontoparietal tumor resection cavity with Gliadel wafers in place and the presence of a large fluid collection. The cavity was debrided surgically and a ventriculostomy catheter was left in place. Cerebrospinal fluid (CSF) cultures were positive for Candida albicans and methicillin-resistant coagulase-negative Staphylococcus spp. Antiinfective therapy with intrathecal and intravenous amphotericin B as well as flucytosine and vancomycin was started. The patient had subsequent improvement in clinical manifestations, resolution of CSF leukocytosis, and mycologic cure.
  
  
  CONCLUSIONS
  Candida meningitis occurs primarily in the setting of immunosuppression, intravenous drug abuse and following neurosurgical procedures. Secondary bacterial and fungal infections have been reported following Gliadel wafer placement in patients with brain tumor resection. Candida meningitis has traditionally been treated with intravenous amphotericin B with or without oral flucytosine. There have been reports of treatment with intrathecal amphotericin B with variable clinical outcomes.
  
  
  CONCLUSIONS
  This case demonstrates successful treatment of Candida meningitis post Gliadel wafer placement with the combination of intrathecal and intravenous amphotericin B. This treatment modality may provide an effective therapeutic option for other patients with Candida meningitis, especially those unresponsive to intravenous therapy.
authors.affiliation: Virginia Commonwealth University Health System, School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA 23298, USA.
authors.forename: Jorie A
authors.initials: JA
authors.lastname: Glick
authors.forename: Robert S
authors.initials: RS
authors.lastname: Graham
authors.forename: Stacy A
authors.initials: SA
authors.lastname: Voils
mesh_terms: D000666:Amphotericin B / Q000008:administration & dosage* / Q000627:therapeutic use*; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D002177:Candidiasis / Q000188:drug therapy* / Q000209:etiology*; D002330:Carmustine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D003652:Decanoic Acids / Q000009:adverse effects; D004343:Drug Implants; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007278:Injections, Spinal; D016921:Meningitis, Fungal / Q000188:drug therapy* / Q000209:etiology; D009837:Oligodendroglioma / Q000188:drug therapy; D011091:Polyesters / Q000009:adverse effects
chemical_list: D000970:Antineoplastic Agents; D003652:Decanoic Acids; D004343:Drug Implants; D011091:Polyesters; C453779:carmustine with prolifeprosan 20; D000666:Amphotericin B; C055401:decanedioic acid-4,4'-(1,3-propanediylbis(oxy))bis(benzoic acid) copolymer; D002330:Carmustine