P272 Fungal brain abscess in the era of COVID 19: an experience from a tertiary care Neurosciences Institute in South India
Authors: S Nagarathna , Samaddar Arghadip , H.B Veena Kumari , Krishnan Priya , M Kavya , Srinivas Dwarakanath 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is ruling the world for more than 2 years since 2020. In 2021, the second wave of COVID-19 attributed to the ‘delta variant’ swept across India, causing significant morbidity and mortality. In addition, the epidemic of COVID-19-associated mucormycosis affected the Indian subcontinent specifically, with a whopping 41 512 cases and 3554 deaths attributed to this dreadful disease.

Methods
The single-center retrospective cross-sectional study was aimed to determine the impact of COVID-19 on fungal brain abscess cases at a non-COVID tertiary care Neurosciences Institute in South India. The study included all cases diagnosed with fungal brain abscess microbiologically (microscopy and/or fungal culture), supported by radiological findings or by histopathological examination. Cases of brain abscess which were negative for fungal elements by microscopy, culture, and imaging were excluded from the study. Fungal culture was done on routine mycological media as per standard procedures. Fungal identification was done by microscopic morphology, MALDI-TOF MS, and ITS sequencing.

Results
A total of 406 cases of brain abscess were recorded between January 2020 and April 2022. Out of these, 26 (6.4%) were cases of fungal brain abscess. In 2020, three out of 153 (2%) cases had a fungal etiology, while it was 10.4% (22/211) in 2021 and 0.24% (1/42) till April 2022. Overall, a male preponderance was observed (20/26, 77% were males). The cases had an even distribution from 6 to 62 years, with no predilection in any particular age group. The most common underlying comorbidity was type 2 diabetes mellitus (13/26, 50%). Four cases had a past history of COVID-19. Radiological suspicion of fungal infection was present in all the cases. Mycological examination (wet mount and 20% KOH mount) of brain abscess pus from all the cases revealed fungal elements. Out of 26 cases, 23 cases showed hyaline, broad aseptate hyphae, 2 showed melanized septate hyphae and 1 showed budding yeast cells with pseudohyphae and arthroconidia on direct microscopy. Culture positivity was observed in 15 cases (57.7%). Out of 23 suspected cases of rhinocerebral mucormycosis based on clinical, radiological, and direct microscopic findings, fungal culture was positive in 13 cases, all of which were identified as Rhizopus arrhizus. Out of two cases that showed melanized hyphae in direct microscopy, one grew a dematiaceous mold that was identified as Cladophialophora bantiana. The other melanized fungus failed to grow in culture. The single case of brain abscess caused by a yeast-like fungus was attributed to Trichosporon dohaense, identified by ITS sequencing. It was initially misidentified as T. ovoides/T. mucoides by VITEK MS due to lack of mass spectral database for T. dohaense.

Conclusions
A significant increase in the incidence of fungal brain abscess has been observed in the COVID-19 era, particularly with each new wave of infection. Clinical features along with imaging and mycological findings are crucial in making an early diagnosis and decision regarding antifungal therapy. Accurate identification to the species level is necessary to guide optimal antifungal therapy as several species exhibit emerging resistance to antifungal drugs.