Pyogenic Meningitis with Vasculitis Caused by Neoscytalidium Dimidiatum

The case of a previously healthy 16-year-old male who presented with an initial 15-day history of progressive headaches, fever, neck stiffness, and vomiting is discussed. A cerebrospinal fluid (CSF) analysis was suggestive of bacterial pyogenic meningitis. However, Gram staining, CSF bacterial and fungal culture, and CSF TB GeneXpert (Cepheid, Sunnyvale, CA) test results were negative. The patient developed vasculitis, which led to further complications, such as cerebral infarcts, subarachnoid hemorrhage, ruptured cerebral aneurysm, and hydrocephalus. The patient worsened despite being subjected to standard treatment protocols for bacterial meningitis, prompting a comprehensive diagnostic evaluation. 16S and 18S-internal transcribed spacer 2 (ITS2) polymerase chain reaction (PCR) test results for bacterial and fungal DNA were negative and positive, respectively. Capillary sequencing of the fungal ITS2 PCR product revealed a rare neuroinvasive fungal pathogen, Neoscytalidium dimidiatum, which was further confirmed using next-generation sequencing. This information enabled targeted antifungal therapy and surgical interventions, which led to significant clinical improvement. The present case underscores the importance of integrating molecular diagnostics and genomic testing into the diagnostic workflow for diagnosing challenging acute central nervous system infections.