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Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 149-151

Ventriculoperitoneal Shunt-Associated Meningitis Caused by Candida auris: A Case Report

Department of Microbiology, Maulana Azad Medical College, New Delhi, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Rohit Chawla
4A/55, Old Rajinder Nagar, New Delhi 110060
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_35_18

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Candida auris was first isolated in Japan in 2008. Since then, it has become an emerging global threat due to its role in outbreaks in healthcare facilities and its decreased susceptibility to multiple antifungal agents. We report a case of ventriculoperitoneal shunt-associated meningitis caused by C. auris in a patient who had a history of tubercular meningitis and hydrocephalus. The isolate was initially misidentified as Candida krusei based on purple-colored colonies on Modified HiCrome Candida Differential Agar but was finally identified as C. auris on VITEK-2 compact (version 8.01). The isolate had a high minimum inhibitory concentration (MIC) for fluconazole, whereas the MICs for other major classes of antifungals were low.

Keywords: Candida auris, meningitis, ventriculoperitoneal shunt

How to cite this article:
Chawla R, Sud A, Ahmad N, Baveja CP. Ventriculoperitoneal Shunt-Associated Meningitis Caused by Candida auris: A Case Report. MAMC J Med Sci 2018;4:149-51

How to cite this URL:
Chawla R, Sud A, Ahmad N, Baveja CP. Ventriculoperitoneal Shunt-Associated Meningitis Caused by Candida auris: A Case Report. MAMC J Med Sci [serial online] 2018 [cited 2021 Jan 16];4:149-51. Available from: https://www.mamcjms.in/text.asp?2018/4/3/149/249028

  Introduction Top

Candida auris is a novel ascomycetous yeast first isolated in 2008 from discharge originating from external auditory canal in a 70-year-old Japanese woman,[1] following which, it has been isolated from many countries, including India,[2],[3] South Africa,[4] the United Kingdom,[5] Brazil,[6] Germany,[7] and the United States.[8] Risk factors for infections due to C. auris are similar to that for infections due to other Candida spp. and include immunosuppressed state, central venous catheter, urinary catheter, recent surgery, parenteral nutrition, and admission to intensive care unit.[8],[9] However, the real burden of C. auris infection may have been underestimated due to the fact that this species is frequently misidentified as Candida famata, Candida haemulonii, Candida sake, Saccharomyces cerevisiae, or Rhodotorula glutinis by various commercial yeast identification systems.[10] Although C. auris has been isolated from ear and wound infections, majority of the published studies have reported bloodstream infections.[1],[2],[11],[12] Invasive infections with multidrug-resistant C. auris has been reported from clinical samples, including cerebrospinal fluid (CSF), peritoneal fluid, blood, urine, and bone in Columbia.[13] The ability of C. auris to cause infection is doubtful in some cases, especially when isolated from urine where it may merely represent carriage.[7] As there are no Clinical and Laboratory Standards Institute or European Committee on Antimicrobial Susceptibility Testing defined breakpoints, the categorical interpretation of antifungal susceptibility profile is currently not available for C. auris. Nonetheless, strains usually display high MICs to fluconazole and are most likely resistant to this antifungal agent. Echinocandins (caspofungin and micafungin) are considered to be the empiric drugs of choice to treat infections due to C. auris.[14] Amphotericin B may be considered for patients not responding to echinocandins, although the response to Amphotericin B is less reliable.[14] We report here, perhaps the first case of ventriculoperitoneal shunt-associated meningitis caused by C. auris, which had a high MIC to fluconazole.

  Case Report Top

A 36-year-old male patient was admitted to the neurosurgery department of a tertiary care hospital in New Delhi in May 2017 with the complaints of altered sensorium. This patient was a known case of tubercular meningitis with hydrocephalus, diagnosed in 2013, for which ventriculoperitoneal shunt was placed. In 2015, the ventriculoperitoneal shunt was replaced due to failure. The patient subsequently recovered and was discharged. In May 2017, shunt failure occurred again. The shunt was exteriorized and replaced in June 2017. However, the patient’s condition did not improve, and in August 2017, a temporary external ventricular drain was placed to provide symptomatic relief, which was removed after a week. The patient was not diabetic and did not have any malignancy or HIV infection. He was not on any immunosuppressive therapy.

The initial CSF samples collected through the exteriorized shunt in June and July 2017 for bacterial and fungal cultures were negative. However, in September 2017, direct microscopy of CSF sample collected through the exteriorized shunt showed single-budding yeast cells along with polymorphonuclear cells [[Figure 1]], whereas nonencapsulated yeast cells were seen on India ink staining. Gram stain of the sample revealed abundant Gram-positive single budding oval yeast cells, 2.0 × 4.0 μm in size, along with polymorphonuclear cells [[Figure 2]]. The sample was negative for capsular polysaccharide antigen of Cryptococcus neoformans by cryptococcal antigen latex agglutination system (CALAS®; Meridian Bioscience, Inc., Cincinnati, Ohio, USA). For bacterial culture, the sample was inoculated on a plate of 5% sheep blood agar, 5% heated blood agar and MacConkey’s agar, and incubated at 37°C. For fungal culture, the sample was inoculated on Sabouraud’s dextrose agar in duplicate, with one tube incubated at 22°C and the other incubated at 37°C. After 24 h of incubation, smooth, off-white-colored, pasty colonies were seen on 5% sheep blood agar and 5% heated blood agar. Similar colonies were seen on Sabouraud’s dextrose agar after 48 h of incubation. Gram stain of the colonies from both bacterial culture media and Sabouraud’s dextrose agar showed Gram-positive single budding yeast cells. The germ tube test was negative. To further identify the isolate, the growth was inoculated on Modified HiCrome Candida Differential Agar (Himedia®; HiMedia Laboratories Pvt. Ltd., Mumbai, Maharashtra, India) which showed purple-colored colonies [[Figure 3]], based on which the organism was provisionally identified as Candida krusei. VITEK-2 Compact (version 8.01), which is the latest version introduced by BioMérieux, Lyon, France with improved identification of C. auris, was used to further characterize the isolate. The isolate was identified as C. auris with ID confidence of very good. The MIC of the isolate to various antifungal agents is given in [Table 1]. Considering the susceptibility profile of the isolate, treatment with an echinocandin (caspofungin or micafungin) was advised. However, the response to therapy could not be assessed as the patient died soon after the diagnosis was made.
Figure 1 Wet mount showing single-budding yeast cells along with polymorphonuclear cells (400×)

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Figure 2 Gram stain of CSF showing abundant Gram-positive single budding oval yeast cells 2.0 × 4.0 μm in size along with polymorphonuclear cells (1000×)

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Figure 3 Growth on modified HiCrome Candida differential agar showing purple-colored colonies

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Table 1 In vitro antifungal susceptibility profile of the Candida auris isolate

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  Discussion Top

C. auris, an emerging cause of invasive candidiasis, is included within the C. haemulonii complex (Group II) based on physiological characteristics and isoenzymatic profile.[15] C. auris fungemia is associated with a high mortality rate, therapeutic failure, and widespread resistance to different antifungal agents.[2],[3],[4],[5] In our study, the patient had a history of tubercular meningitis and hydrocephalus requiring the placement of ventriculoperitoneal shunt, with subsequent development of ventriculoperitoneal shunt-associated meningitis due to C. auris. The ability of C. auris to form biofilms[16] may have been a contributory factor in the development of ventriculoperitoneal shunt-associated meningitis. The patient had a history of prolonged hospitalization on multiple occasions, urinary catheterizations, and placement of peripheral venous lines, all of which may also have contributed to the development of infection. Although C. auris has been frequently isolated from bloodstream, ear, and wound infections, to the best of our knowledge, this is perhaps the first report of ventriculoperitoneal shunt-associated meningitis caused by C. auris. Significantly, growth on Modified HiCrome Candida Differential Agar (Himedia®) showed purple colonies, which misidentified the organism as C. krusei. Hence, the species-level identification of C. auris isolates must rely on methods such as matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), molecular sequencing, and updated commercial identification systems capable of identifying C. auris. Similar to other studies, C. auris isolate in our study was also found to have a high MIC to fluconazole.[2],[3],[8] Multidrug-resistant strains have been reported in many studies, whereas some isolates have been reported to be resistant to all the three major classes of antifungals.[13],[17] However, in our study, the MIC of C. auris was found to be low for echinocandins, flucytosine, and amphotericin B.

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  References Top

Satoh K, Makimura K, Hasumi Y, Nishiyama Y, Uchida K, Yamaguchi H. Candida auris sp. nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanese hospital. Microbiol Immunol 2009;53:41-4.  Back to cited text no. 1
Sarma S, Kumar N, Sharma S, Govil D, Ali T, Mehta Y et al. Candidemia caused by amphotericin B and fluconazole resistant Candida auris. Indian J Med Microbiol 2013;31:90-1.  Back to cited text no. 2
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Chowdhary A, Sharma C, Duggal S, Agarwal K, Prakash A, Singh PK et al. New clonal strain of Candida auris, Delhi, India. Emerg Infect Dis 2013;19:1670-3.  Back to cited text no. 3
Magobo RE, Corcoran C, Seetharam S, Govender NP. Candida auris-associated candidemia, South Africa. Emerg Infect Dis 2014;20:1250-1.  Back to cited text no. 4
Schelenz S, Hagen F, Rhodes JL, Abdolrasouli A, Chowdhary A, Hall A et al. First hospital outbreak of the globally emerging Candida auris in a European hospital. Antimicrob Resist Infect Control 2016;5:35.  Back to cited text no. 5
Prakash A, Sharma C, Singh A, Kumar Singh P, Kumar A, Hagen F et al. Evidence of genotypic diversity among Candida auris isolates by multilocus sequence typing, matrix-assisted laser desorption ionization time-of-flight mass spectrometry and amplified fragment length polymorphism. Clin Microbiol Infect 2016;22:277.e1-9.  Back to cited text no. 6
European Centre for Disease Prevention and Control. Candida auris in healthcare settings—Europe—19 December 2016. Stockholm: ECDC; 2016.  Back to cited text no. 7
Vallabhaneni S, Kallen A, Tsay S, Chow N, Welsh R, Kerins J et al. Investigation of the first seven reported cases of Candida auris, a globally emerging invasive, multidrug-resistant fungus—United States, May 2013–August 2016. MMWR Morb Mortal Wkly Rep 2016;65:1234-7.  Back to cited text no. 8
Sarma S, Upadhyay S. Current perspective on emergence, diagnosis and drug resistance in Candida auris. Infect Drug Resist 2017;10:155-65.  Back to cited text no. 9
Chowdhary A, Voss A, Meis JF. Multidrug-resistant Candida auris: ‘New kid on the block’ in hospital-associated infections? J Hosp Infect 2016;94:209-12.  Back to cited text no. 10
Emara M, Ahmad S, Khan Z, Joseph L, Al-Obaid I, Purohit P et al. Candida auris candidemia in Kuwait, 2014. Emerg Infect Dis 2015;21:1091-2.  Back to cited text no. 11
Calvo B, Melo AS, Perozo-Mena A, Hernandez M, Francisco EC, Hagen F et al. First report of Candida auris in America: Clinical and microbiological aspects of 18 episodes of candidemia. J Infect 2016;73:369-74.  Back to cited text no. 12
Morales-López SE, Parra-Giraldo CM, Ceballos-Garzón A, Martínez HP, Rodríguez GJ, Álvarez-Moreno CA et al. Invasive infections with multidrug-resistant yeast Candida auris, Colombia. Emerg Infect Dis 2017;23:162-4.  Back to cited text no. 13
Sears D, Schwartz BS. Candida auris: An emerging multidrug-resistant pathogen. Int J Infect Dis 2017;63:95-8.  Back to cited text no. 14
Ruiz Gaitán AC, Moret A, López Hontangas JL, Molina JM, Aleixandre López AI, Cabezas AH et al. Nosocomial fungemia by Candida auris: First four reported cases in continental Europe. Rev Iberoam Micol 2017;34:23-7.  Back to cited text no. 15
Sherry L, Ramage G, Kean R, Borman A, Johnson EM, Richardson MD et al. Biofilm-forming capability of highly virulent, multidrug-resistant Candida auris. Emerg Infect Dis 2017;23:328-31.  Back to cited text no. 16
Lockhart SR, Etienne KA, Vallabhaneni S, Farooqi J, Chowdhary A, Govender NP et al. Simultaneous emergence of multidrug resistant Candida auris on three continents confirmed by whole genome sequencing and epidemiological analyses. Clin Infect Dis 2017;64:134-40.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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