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Lack of efficacy: case report A 28-year-old woman exhibited lack of efficacy while receiving amphotericin-B and voriconazole for Aspergillus fumigatus meningitis [dosages not stated; not all routes stated]. The woman presented due to 2-week history of fever and headache post C-section two months prior. She had been admitted and investigated in another clinic showing negative urine, blood and CSF cultures. CSF examination showed lymphocytic predominance with mild elevation in proteins. She had received empirical unspecified anti-tubercular treatment and dexamethasone for suspected meningeal tuberculosis two weeks prior. On current presentation, she appeared well, except for tachycardia. Her unspecified antitubercular treatment was discontinued, and she was hospitalised for further evaluation. An auto‑immune workup including IgG4 disease, Wegener’s and Sarcoidosis was negative. A MRI of the brain and cervical cord revealed significant inflammatory lesion in the dura with extension into the nerve root. Therefore, shewas re-started on empirical treatment with unspecified anti-tubercular treatment and dexamethasone. Her fever improved with high dose dexamethasone. Thereafter, she was discharged with weekly follow-up. She had symptomatic recurrence 5 weeks after discharge. Therefore, Histology of the biopsy specimen collected from the left L1‑L2 lumbar root lesion suggested fungal infection. Intraoperative fungal culture grew Aspergillus fumigatus. She was diagnosed with Aspergillus fumigatus meningitis possibly after spinal anaesthesia for C-section. Thereafter, she started receiving high-dose voriconazole, and dexamethasone was rapidly tapered. She was discharged with a plan to continue voriconazole. Her symptoms continued despite high-dose voriconazole. While hospitalised, she developed hypotension and was placed on Ommaya reservoir. She started receiving 14-day course of intraventricular amphotericin-B along with voriconazole. Additionally, she received unspecified antibacterials [antibiotics] for possible secondary bacterial sepsis. Despite the treatment, her headache and vomiting persisted. Her condition continued to deteriorate with episodes of hypotension, which required unspecified inotropic support. A CSF culture and TB panel showed negative results. She was given empirical antibiotic treatment with unspecified carbapenem without any clinical improvement. She was discharged to another centre on request and died there after 2 weeks [cause of death not stated]. Rathish B, et al. Aspergillus fumigatus meningitis in an immunocompetent young woman. Indian Journal of Pathology and Microbiology 63: 488-490, No. 3, Sep 2020. 803519291 Available from: URL: http://doi.org/10.4103/IJPM.IJPM_252_19

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Reactions 5 Dec 2020 No. 1833