To review the case of a patient who presented with a diagnostically elusive chronic meningitis, who after several months of repeated culture of the cerebrospinal fluid (CSF), was found to have an infectious meningitis due to Candida dubliniensis.

Chronic meningitis is a diagnostically challenging entity, for which the cause remains unknown in at least one third of patients [Hildebrand and Aoun, 2003].  The differential diagnosis for chronic meningitis is broad, including infectious, rheumatologic, and neoplastic causes, in addition to aseptic meningitis due to toxic exposures. 

A 34-year-old woman with a history of ANA+ arthralgias and intravenous opiate abuse (in remission for one year) presented with several months of worsening headache, visual obscurations, and double vision associated with drenching night sweats.  Exam was notable for papilledema, with a left abducens palsy and nuchal rigidity. Initial lumbar puncture revealed an opening pressure of 54 cm H2O, 400 WBC (58% PMN, 34% lymphocytes), glucose 24, total protein 134.  HIV testing was negative.  She was treated initially with broad antibiotic coverage for meningitis.  A broad work up for infectious, inflammatory and neoplastic causes was negative. Antibiotics were discontinued.  She was suspected to have aseptic meningitis from meloxicam use.  Despite cessation of all NSAIDs, she was readmitted two months later with recurrent symptoms.  Repeated lumbar punctures showed persistently elevated opening pressure with mixed CSF pleocytosis and hypoglycorrhachia.  In total, she underwent 11 lumbar punctures before CSF cultures finally demonstrated Candida dulbiniensis.  She was started on anti-fungal treatment, with resolution of persistent night sweats and headache.  Her last lumbar puncture showed an improving pleocytosis in the CSF.

This case highlights the challenges in obtaining a diagnosis in chronic meningitis.  Even in the absence of an immunocompromised state, IV drug use should raise suspicion for infectious causes.