Frequent central nervous system (CNS) infections in the immunosuppressed patient

Infections of the central nervous system among immunocompromised patients are of major clinical relevance due to the high morbidity and mortality they convey. The clinical approach to central nervous system (CNS) infections is based on keeping a low threshold of suspicion and recognizing the classic clinical syndromes together with the particularities that occur in immunocompromised patients: subacute onset, subtle and overlapped clinical presentation, and the presence of opportunistic agents in addition to traditional pathogens and sometimes the presence of more than one infectious agent. The etiologic study should be oriented according to the clinical presentation syndrome and the underlying immunodepression model. Imaging studies should always be performed, and the cerebrospinal fluid should be analyzed. Finally, and particularly in the case of brain lesions with mass effect, early tissue collection should be considered. The treatment has to be directed to agents related to the clinical syndrome and the underlying immune defect model identified. The timely initiation of empirical antimicrobials is warranted, and it should include broad-spectrum antimicrobials with adequate penetration to the central nervous system. Finally, the availability of adjunctive therapies to antimicrobials that may have additional utility in particular cases (e.g., corticoids in the case of pneumococcal meningitis) should be taken into account.