Open Access Case

Report DOI: 10.7759/cureus.3140

Device-associated Central Nervous System

Infection Caused by Candida parapsilosis
Gurpreet S. Bhalla 1 , Muqtadir Malik 2 , Manbeer S. Sarao 3 , Kuntal Bandyopadhyay 4 ,
Pratiksha Singh 3 , Satish Tadepalli 5 , Lavan Singh 1

1. Microbiology, Army Hospital (research and Referral), New Delhi, IND 2. Microbiology, Army Hospital
(research and Referral), Delhi, IND 3. Internal Medicine, UPMC Pinnacle, Harrisburg, USA 4. Station
Health Organization, Military Hospital, Amritsar, Amritsar, IND 5. Internal Medicine, Hackensack
Meridian - Ocean Medical Center, Edison, USA

 Corresponding author: Manbeer S. Sarao, [email protected]

Disclosures can be found in Additional Information at the end of the article

Abstract
Meningitis is a common and life-threatening infection of the central nervous system (CNS) in
infants with long-term and disabling sequelae like hydrocephalus. Hydrocephalus is treated by
diverting cerebrospinal fluid (CSF) either to another body cavity (via CSF shunt) or externally
(via CSF drain) which are prone to infection. Though rare, Candida parapsilosis (C. parapsilosis)
is a known pathogen in device-associated CNS infections and has been reported in both,
infants and adults.

A six-month-old male infant was brought to the hospital with disproportionate head
enlargement of three months duration. Magnetic resonance imaging (MRI) was suggestive of
gross asymmetrical hydrocephalus. An external ventricular drain (EVD) was placed, and
vancomycin and meropenem were started. Four weeks later, he developed a fever with a
blocked EVD. Repeat MRI revealed gross asymmetric dilatation of left lateral ventricle along
with pneumocephalus in the right periventricular region. A right temporoparietal craniotomy
with drainage of a multiloculated abscess was done along with the removal of right EVD and
placement of left EVD. CSF showed pan-susceptible C. parapsilosis and fluconazole was started.
Despite treatment, CSF continued to grow C. parapsilosis through day 10. The EVD was
removed, and an Ommaya reservoir along with the ventricular catheter was placed for better
interventricular antibiotic administration. After day 13 CSF became sterile. Ommaya reservoir
was removed, fluconazole was continued for three weeks, and a ventriculoperitoneal shunt was
placed five weeks later.

The device-associated CNS infections are insidious with nonspecific manifestations making
diagnosis difficult. C. parapsilosis has been increasing in prevalence, especially in
immunocompromised hosts, infants, and in patients with indwelling catheters. Amphotericin B
Received 07/16/2018
or fluconazole is the usual treatment with excellent outcomes and no mortality. This case
Review began 07/27/2018
Review ended 08/07/2018 underscores the need for suspicion of C. parapsilosis as a cause of device-associated CNS
Published 08/14/2018 infections.
© Copyright 2018
Bhalla et al. This is an open access
article distributed under the terms of
Categories: Internal Medicine, Pediatrics, Infectious Disease
the Creative Commons Attribution
License CC-BY 3.0., which permits
Keywords: device-associated, cns infection, candida, hydrocephalus, evd, ommaya
unrestricted use, distribution, and

Introduction
reproduction in any medium,
provided the original author and
source are credited.
Meningitis of bacterial or nonbacterial origin is a common and life-threatening infection of the

How to cite this article

Bhalla G S, Malik M, Sarao M S, et al. (August 14, 2018) Device-associated Central Nervous System
Infection Caused by Candida parapsilosis. Cureus 10(8): e3140. DOI 10.7759/cureus.3140
 central nervous system (CNS) in infants. With the advent of modern medicine, the mortality
rate has decreased with a proportionate increase in the risk for long-term and disabling
sequelae. Meningitis in infants can lead to various postinfectious sequelae among which
hydrocephalus is common. It can result from blockage of the cerebrospinal fluid (CSF) flow at
the aqueduct of Sylvius or the outlets of the fourth ventricle, obstruction of flow within the
subarachnoid spaces, or an impediment to CSF absorption.

Hydrocephalus requires hospital admission and is treated by diverting CSF either to another
body cavity (via CSF shunt) or externally (via CSF drain). Both CSF shunts and CSF drains are
prone to infection with higher infection rates noted in those undergoing successive shunt
revisions. Gram-positive cocci account for a majority of these cases, but Gram-negative and
positive bacilli, fungi, and antimicrobial resistant bacteria have also been reported [1-2]. Fungi,
especially Candida species (Candida spp.), have emerged as an important pathogen in such
infections as evidenced by increasing literature. Though rare, Candida parapsilosis (C.
parapsilosis) is a known pathogen in device-associated CNS infections and has been reported
not only in infants but also in adults [3].

A case of device-associated CSF infection by C. parapsilosis in an infant with hydrocephalus is

being reported.

Case Presentation
A six-month-old male infant, with a significant past medical history of neonatal meningitis on
the second day of life, was brought with complaints of disproportionate head enlargement for
three months duration. Initial magnetic resonance imaging (MRI) was suggestive of gross
asymmetrical hydrocephalus with obstruction at the level of the aqueduct, and no signs of
ependymal thickening (Figure 1).

2018 Bhalla et al. Cureus 10(8): e3140. DOI 10.7759/cureus.3140 2 of 6

 FIGURE 1: Magnetic resonance imaging scan showing gross
asymmetrical hydrocephalus.

Ventricular tap was done, and CSF was received for cytology, biochemical analysis, and culture.
Cultures were sterile, and there were no features of infection.

For intra-cranial pressure reduction, an external ventricular drain (EVD) was placed, and
intraventricular vancomycin (10 mg 12 hourly) was started along with parenteral vancomycin
(120 mg 8 hourly) and meropenem (240 mg 8 hourly). Serial CSF monitoring was continued.

Four weeks later, the child developed a fever. It was noted that the EVD had blocked and a
repeat MRI scan revealed gross asymmetric dilatation of left lateral ventricle along with air-
fluid level in right periventricular region suggestive of pneumocephalus. The child was
managed by right temporoparietal craniotomy and excision of multiloculated abscess done
along with the removal of right EVD and placement of left EVD.

The CSF samples received showed features of infection and Gram-positive budding yeast was
seen on a direct stain (Figure 2).

2018 Bhalla et al. Cureus 10(8): e3140. DOI 10.7759/cureus.3140 3 of 6

 FIGURE 2: Gram stain of cerebrospinal fluid showing gram-
positive budding yeast.

Candida parapsilosis was isolated from culture and was susceptible to all antifungals.
Fluconazole (50 mg 24 hourly) was started, and serial monitoring of CSF continued. Despite
treatment, daily CSF samples continued to grow C. parapsilosis through day 10. The EVD was
removed, and an Ommaya reservoir along with a ventricular catheter was placed for better
intraventricular antibiotic administration (vancomycin 10 mg 12 hourly). CSF samples taken 13
days and onwards were sterile. Clinically, the infant became afebrile and stable.

Antifungal therapy was continued for three weeks. The Ommaya reservoir was removed, and a
ventriculoperitoneal shunt was placed five weeks later. Three months later, the infant remains
asymptomatic.

Discussion
The device-associated CNS infections have nonspecific manifestations and have an insidious
nature, which makes diagnosis difficult. Retrograde infection is the most likely mechanism of
infection of CSF drains. Microorganisms may enter the device by tracking from the exit site
alongside the device, gaining access to the fluid column that drains CSF. CSF shunts and CSF
drains are prone to infection with a reported incidence rate varying from 4% to 17% [4].

2018 Bhalla et al. Cureus 10(8): e3140. DOI 10.7759/cureus.3140 4 of 6

 Bacteria remain the most prevalent cause of device-associated CNS infections. Though fungi
are rare causes, the growing evidence suggests that fungal infections should be a differential in
device-associated infections. Past studies have shown a varying incidence of shunt infections
caused by fungi. Chiou et al. [5] in a retrospective study performed in 1994 reported that fungi
were responsible for 17% (8/48) of shunt infections. Baradkar et al. [6] reported that 25% of
shunt infections were due to fungi. Much higher infection rates with Candida spp. of 74% were
reported by Fernandez et al. [7].

As in the present case, literature [8-9] mentions that 77% of Candida infections developed
within three months of shunt manipulation, suggesting inoculation of the organism during the
procedure. Risk factors reported for candidal device infections include the administration of
broad-spectrum antibiotics, prior meningitis, CSF leakage, abdominal surgery, immune
suppression and after medical device insertion. Clinical presentation of device-associated
infection depends upon its location. Transient candidemia with the secondary colonization of
shunts and drains have been suggested by other reports as a possible source of infecting
Candida organisms [10].

As fungal infections are rare causes of device-associated CNS infections, fungi are initially not
considered as the implicating pathogen. The only definitive diagnostic test is the direct
observation and culture of the CSF. C. parapsilosis has been increasing in prevalence, especially
in immunocompromised hosts, neonates, and in patients with indwelling catheters [11].

As reported by earlier studies, C. albicans remains the most important pathogen, followed by C.
parapsilosis and C. glabrata with symptoms appearing as early as one week to as delayed as one
year [5-6]. Amphotericin B or fluconazole is the usual treatment with excellent outcomes and
no mortality [3, 5-7, 9].

Candida parapsilosis is the most common fungus isolated from human hands, and given its
ability to transfer horizontally, it can contaminate medical devices with ease. A study reported
hand colonization of more than 25% of healthcare workers in a community hospital with C.
parapsilosis [12]. Thus, in patients with CNS devices, adherence to a checklist consisting of
hand hygiene and appropriate skin preparation before insertion, use of sterile barriers (sterile
gloves, sterile gown, cap, mask, and large sterile drape), and adherence to the policy for EVD
maintenance can significantly reduce the infection rates. The use of “practice bundles” may
also be valuable in the development of standardized protocols which are effective at lowering
CSF shunt infection rates.

This case underscores the need for suspicion of C. parapsilosis as a cause of device-associated
CNS infections.

Conclusions
Device-associated CNS infections are insidious with nonspecific manifestations making
diagnosis difficult. C. parapsilosis has been increasing in prevalence, especially in
immunocompromised hosts, neonates, and in patients with indwelling catheters. It has a high
affinity for parenteral nutrition, frequently colonizes the hands of healthcare workers, and
forms a biofilm on prosthetic surfaces and central venous catheters. Extraventricular drainage,
therapy with amphotericin B or fluconazole (intravenous or intraventricular), and insertion of a
new shunt remain the principal components of the treatment regimen for pediatric fungal
shunt infections. There is no established recommendation for the duration of treatment of
pediatric fungal shunt infection or the role of other newer antifungal drugs. This case
underscores the need for suspicion of C. parapsilosis as a cause of device-associated CNS
infection.

2018 Bhalla et al. Cureus 10(8): e3140. DOI 10.7759/cureus.3140 5 of 6

 Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared
that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All
authors have declared that there are no other relationships or activities that could appear to
have influenced the submitted work.

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