Meningitis, typically subacute in nature, is caused by a variety of fungal organisms in both immunocompetent and immunocompromised individuals. Fungal infections are initially acquired via inhalation of fungal spores and a subsequent pulmonary infection. At times, this initial infection is asymptomatic and self-limited, yet a dormant infection and impaired cell-mediated immunity may permit reactivation of the fungus with dissemination to the central nervous system (CNS). Patients typically present with ongoing headaches, stiff neck, low-grade fever, and lethargy for days to weeks before presentation. Other common symptoms are night sweats and cranial nerve abnormalities.

Common causes of fungal meningitis include:

• Cryptococcus neoformans – Found worldwide in soil and bird excrement. Typically affects immunocompromised patients such as those with HIV, organ transplantation, or cancer. However, it is increasingly common in seemingly healthy persons in whom signs such as fever may be absent, risking diagnostic delay and poor outcomes.
• Histoplasma capsulatum – Endemic to the Ohio and Mississippi River valleys and parts of Central and South America. Also more common in immunocompromised patients.
• Coccidioides immitis – Endemic to the desert southwestern United States, northern Mexico, and Argentina. May be an indolent infection and prominently has pulmonary infections.
• Candida albicans – Often occurs due to disseminated spread of infection, and most common in neonates.

Rarely, meningitis may persist for 4 weeks and is then considered chronic meningitis.