A Candid Look at a Missed Diagnosis

Tenth lumbar puncture was performed. It returned a positive culture of Candida albicans. Smears however were still negative. Treatment with liposomal amphotericin B was initiated and led to resolution of headaches and improvement of the bilateral disc edema. The patient was discharged home after 2 weeks. Unfortunately, she was readmitted 3 weeks later with the recurrence of all original symptoms. High protein and low glucose in CSF usually betoken infectious meningitis, with neoplastic and sarcoid-associated meningitis as less likely causes. In this case bacterial and viral meningitis were unlikely given that symptoms were present for a long time, and the patient was relatively well. The remaining most likely cause was fungal meningitis. Repeated testing for cryptococcal antigen, histoplasmosis, blastomyces and coccidium (most common causes of fungal meningitis) was negative. The patient was considered immunocompetent (repeated testing for HIV was negative) although the past history of intravenous drug abuse was likely a risk factor for fungal meningitis. After a prolonged course of intravenous and oral antifungal therapy and several readmissions, visual acuity improved to 20/40 bilaterally, optic nerve head edema resolved, and visual fields improved. The patient was left with residual bilateral optic neuropathy. When initial MRI was re-examined, subtle enhancement of meninges was noticed which was previously overlooked.