HYDROCEPHALUS AFTER INTRA-UTERINE FUNGALINFECTION

BY

A. F. BURRYFrom the Christchurch Hospital, New Zealand

(RECEIVED FOR PUBLICATION OCTOBER 30, 1956)

Fungal infections of thenervous system are uncommonbut are mentioned by Russell(1949) as a possible cause ofhydrocephalus. Intra-uterinemeningitis from any cause hasbeen reported only once.Crosby, Mosberg and Smith(1951), in reporting this case,reviewed the literature onmeningitis of the newborn upto 1951 and could find no othercase acceptable as having aninception in the intra-uterine period.The following case appears to be unique

hydrocephalus resulted from an intra-uterinof meningitis due to a fungus.

Case ReportBaby S. was born on August 8, 1954, after

forceful labour lasting two hours. The presentzvertex, L.O.A. The mother's health had beeithroughout the pregnancy. There was ncsuggestive of vaginal thrush on close questiorantibiotics had not been given during the piThe only previous child, born in 1949, waswell.

Conception in the present case had followe

F-IG. 1.-Occipital poles snowing organized exudate in subar;

FIG. 2.-Lining of lateral ventricle showing roughening and granules.

on dilatation and curettage and tubal insufflation, carriedout because of apparent infertility.The baby, a boy, weighed 7i lb. at birth. He was

slow to breathe and cry but responded well to oxygenand incubation. At the time of delivery some haemor-rhagic areas were noted on the face, attributed to bruisingat delivery. These faded within a fortnight. Soonafter birth it was noticed that the baby's sucking andswallowing reflexes were poor and for the first fortnighthe was tube fed. For the first 10 days his tenure of lifewas precarious. Twitching of the left eyelid was firstnoted on the third day and subsequently both eyes andthe left side of the face twitched at intervals. Examina-tion on the fifth day showed undue separation of the skullsutures and a diagnosis of hydrocephalus was suggested.From the end of the second week there was some

improvement in the baby's'b f condition. Sucking improved and

i _ bottle feeding was started. Thehead diminished in size from acircumference of 15i in. on the18th day to 141 in. on the 29thday. On the 33rd day he had aconvulsion and began to passfrequent green motions. His con-dition progressively deterioratedand he died on the 37th day.

Post-mortem examination wasperformed by the author 18 hoursafter death. The body was that

achnoid space. of a normally developed but161

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FIG. 5.

FIG. 3.-Low-power view of a section of the area shown in Fig. r.Haematoxylin and eosin.

FIG. 4.-Section of lining (low-power view) of lateral ventricle. Notelayer of organized exudate and dark, partly calcified fungal material

Haematoxylin and eosin.

FIG. 5.-P.A.S.-stained section (high-power view) of area seen in Fig. 4,showing fungal spores and mycelia. The darkly staining mass at the

top is a calcifying mass of spores.

rIG. a.

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HYDROCEPHALUS AFTER INTRA-UTERINE FUNGAL INFECTION 163

rather poorly nourished male infant weighing 3,280 g.The trachea and bronchi contained yellowish mucoidmaterial and the lungs showed basal collapse and con-gestion. The small intestine was slightly dilated andcontained watery yellowish fluid and the contents of thelarge bowel were also watery and yellow.The skull measured 14 in. in circumference, the cranial

bones were thinned and the sutures were widened. Thecerebral hemispheres were tense and distended withmarked flattening of the sulci. A striking feature wasthe obliteration of sulcal markings over the occipitalpoles by pale organized exudate (Fig. 1). There were afew fine adhesions about the base of the brain. Therewas gross hydrocephalus involving the lateral and thirdventricles. The corpus callosum was grossly thinned.The aqueduct was narrow but patent. The lining of thelateral ventricles was roughened at some points and therewere scattered small yellowish projections into thelumen (Fig. 2).The possibility of toxoplasmosis was entertained and

the eyes were examined and sectioned but were normalmacroscopically and microscopically.

Sections of the exudate over the occipital pole and toa lesser extent at other points, mainly at the base of thebrain, showed marked meningeal thickening withadhesions to the pia (Fig. 3).No organisms could be demonstrated in the organized

exudate which showed very sparse lymphocytic infiltra-tion. Sections from the lining of the lateral ventriclesshowed partial loss of the ependymal layer, the cells ofwhich were elsewhere largely flattened to cuboidal.Beneath a layer of glial scarring, and at some pointspenetrating more deeply into the brain substance, were.irregular masses of partly calcified necrotic material andstructures identifiable by P.A.S. stains as hyphae andspores of a fingus (Figs. 4, 5). These masses of fungiand necrotic material formed the yellowish granulesvisible macroscopically. There was a sparse lympho-cytic infiltration around the fungal masses.

Sections from a number of other organs, includinglung, liver and pancreas, showed no evidence of dissemin-ated fungal infection.The final morbid anatomical diagnosis was hydro-

cephalus after intra-uterine fungal infection, gastro-enteritis and inhalation of vomitus.

CommentWas the infection truly intra-uterine? There are

several reasons for this belief. First the distributionof exudate over the occipital pole is best explainedby the baby presenting as a vertex in the L.O.A.position when the occipital poles would be dependent.Secondly the histological appearances with wellestablished scarring and calcification suggest a longerduration of the inflammatory process than fiveweeks. Thirdly the baby was feeble from birth andhydrocephalus was suspected from as early as the

fifth day. It is hardly likely that hydrocephaluscould develop in such a short time if a post-natalinfection were postulated.

Source of Infection. Monilial vaginal infectionsare common during pregnancy and it is possible thatthis patient had a subclinical infection which insome way reached the placenta and was transmittedthrough it. Another possibility is that the infectionwas introduced to tubes or uterine cavity in thecourse of the dilatation and curettage and tubalinsufflation carried out not long before conceptiontook place. The infecting organism passing throughthe placenta may have reached the choroidal plexusand primarily infected the lateral ventricles. Thesmall calibre of the aqueduct could have diminishedthe spread of infection to the meninges, or theabsence of demonstrable organisms in the meningesmight be due to the more efficient response of themeninges to infection.

Nature of the Infection. Unfortunately no cultureswere made before fixation of the brain so thatidentification of the infecting organism is incom-plete. The presence of septate pseudomycelia andsmall spores suggests that Candida albicans, themost likely pathogen, is responsible for thisinfection.

Cause of the Hydrocephalus. The clinical coursewith apparent diminution in the degree of hydro-cephalus suggests that a blockage in the aqueductmay have resolved. Morris, Kalz and Lotspeich(1945), describing a case of monilial meningitis,similarly noted that the reactive process was greaterin the ventricular cavities than in the subarachnoidspace.

SummaryA case is described of hydrocephalus in an infant,

due to a fungal infection of the meninges. Reasonsare given for the belief that the infection was intra-uterine.

I have to thank Dr. L. C. Averill for permission topublish this case and Drs. D. T. Stewart and G. C. T.Burns and Professor J. A. R. Miles for their help andadvice.

REFERENCES

Crosby, R. M. N., Mosberg, W. H. and Smith, G. W. (1951). J.Pediat., 39, 94.

Morris, A. A., Kalz, G. G. and Lotspeich, E. S. (1945). Arch. Neurol.Psychiat. (Chicago)), 54, 361.

Russell, D. S. (1949). Spec. Rep. Ser. med. Res. Coun. (Lond.).No. 265.

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