Azole-Resistant Candida albicans Meningitis in an Unvaccinated Infant with Fatal Outcome: A Case Report from Yemen

Abstract

Background:
Fungal meningitis caused by Candida species is a rare but life-threatening condition in infants, frequently associated with delayed diagnosis and high mortality. Central nervous system involvement by Candida albicans remains uncommon outside neonatal intensive care settings, posing significant diagnostic and therapeutic challenges, particularly in resource-limited countries.

Case Presentation:

We report a fatal case of azole-resistant Candida albicans meningitis in an unvaccinated male infant aged less than one year who presented with fever and recurrent seizures of one-week duration. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, marked hypoglycorrhachia, and elevated protein levels despite a clear macroscopic appearance. Direct microscopy and fungal culture confirmed Candida albicans, while routine bacterial cultures were negative. Antifungal susceptibility testing demonstrated resistance to multiple azole agents, including fluconazole and voriconazole, with preserved susceptibility to amphotericin B. Hematological evaluation showed leukocytosis with relative lymphocytosis, and serum electrolyte analysis revealed significant hyponatremia. Despite clinical management, the patient’s condition deteriorated, resulting in death.

Conclusion:
This case highlights the diagnostic complexity and poor prognosis of Candida albicans meningitis in infancy, particularly in the presence of azole resistance. Early inclusion of fungal investigations in suspected meningitis, prompt species identification, and antifungal susceptibility testing are essential for guiding effective therapy. Increased awareness of invasive and drug-resistant Candida infections is critical to improving outcomes in pediatric patients in resource-limited settings.