Clival canal defect: a rare cause of recurrent meningitis and fungal brain abscess in an immune-competent child

A girl in her early childhood years (2-5 years) presented with multiple episodes of meningitis. Following the sixth episode, she clinically deteriorated with the development of multiple brain abscesses and hydrocephalus, requiring a ventriculoperitoneal shunt and prolonged antibiotic and antifungal therapy. MRI of the brain revealed a possible anatomical defect at the C1 level of the cervical spine, communicating into the nasopharyngeal cavity. Needle aspiration of the brainstem collection confirmed <i>Aspergillus fumigatus</i> on molecular testing. A transoral endoscopic adenoidectomy exposed an underlying mucosal defect communicating with the base of the clivus. Following successful repair of the defect, she showed significant improvement with no further episodes of meningitis.This case highlights the benefit of a multidisciplinary team approach and the need for any patient with recurrent meningitis to undergo extensive evaluation. Long-term isavuconazole has shown excellent efficacy and tolerability in our case. Control of infection may not be possible without surgical correction.