Meningeal Sporotrichosis Due to Sporothrix brasiliensis: A 21-Year Cohort Study from a Brazilian Reference Center

Abstract

Meningeal sporotrichosis is rare and occurs predominantly in immunosuppressed individuals. This retrospective study explored clinical and laboratory characteristics, treatment, and prognosis of patients with disseminated sporotrichosis who underwent lumbar puncture (LP) at a Brazilian reference center from 1999 to 2020. Kaplan–Meier and Cox regression models were used to estimate overall survival and hazard ratios. Among 57 enrolled patients, 17 had meningitis. Fifteen (88.2%) had HIV infection, and in 6 of them, neurological manifestations occurred because of the immune reconstitution inflammatory syndrome (IRIS). The most frequent symptom was headache (88.2%). Meningeal symptoms at first LP were absent in 7/17 (41.2%) patients. Sporothrix was diagnosed in cerebrospinal fluid either by culture or by polymerase chain reaction in seven and four patients, respectively. All but one patient received prolonged courses of amphotericin B formulations, and seven received posaconazole, but relapses were frequent. Lethality among patients with meningitis was 64.7%, with a higher chance of death compared to those without meningitis (HR = 3.87; IC95% = 1.23;12.17). Meningeal sporotrichosis occurs mostly in people with HIV and can be associated with IRIS. Screening LP is indicated in patients with disseminated disease despite the absence of neurological complaints. Meningitis is associated with poor prognosis, and better treatment strategies are needed.

Clinical characteristics, diagnosis, and treatment of central nervous system sporotrichosis: Systematic review and meta‐analysis

“…43 In situations where itraconazole is not well-tolerated, fluconazole and posaconazole may be considered alternatives. 7,44,45 It is important to note that not all antifungal agents effectively penetrate the bloodbrain barrier. While fluconazole exhibits lesser antifungal activity against S. schenckii compared to itraconazole, its penetration into CNS is significantly greater.…”

“…In conclusion, we included 24 manuscripts, with 52 cases of CNS sporotrichosis published from 1966 to 2023. 6,7, We present the flow diagram in Figure 1.…”

Clinical factors associated with systemic sporotrichosis in Brazil

“…On the other hand, CNS involvement may indicate the highly severe manifestation of sporotrichosis, posing a significant risk of death. 8,10,20,47 Sporotrichosis should be considered a differential diagnosis of meningitis in immunosuppressed patients living in sporotrichosis endemic areas. 47 An important observation from this study was the association between the detection of fungal structures in the Giemsa or Panoptic stains with SF and death.…”

“…Although nonspecific, when these symptoms are associated with skin lesions caused by Sporothrix spp., an investigation of SF should be carried out. On the other hand, CNS involvement may indicate the highly severe manifestation of sporotrichosis, posing a significant risk of death 8,10,20,47 . Sporotrichosis should be considered a differential diagnosis of meningitis in immunosuppressed patients living in sporotrichosis endemic areas 47 …”

“…7,[16][17][18] It is well known that immunocompromised patients, especially people living with HIV, present the disseminated form of sporotrichosis, in which the fungus can affect bones, mucous membranes, eyes, lungs and the central nervous system (CNS), posing a severe risk of death. 7,8,12,16,[18][19][20][21][22][23][24] Other conditions, such as diabetes, alcoholism, granulomatous disease, cirrhosis, kidney transplantation and chronic corticosteroid use, are suggested as predisposing factors for Sporothrix dissemination to the blood and other organs. 8,18,19,23,25 However, the occurrence of disseminated sporotrichosis in apparently immunocompetent individuals seems to be increasing worldwide.…”