Invasive mould infections of the central nervous system in the Indian population: a cohort study (2004–2025)

Background Central nervous system (CNS) invasive mould infection (IMI) is a rare but life-threatening condition. Limited large-scale studies hinder the understanding of its clinical characteristics and optimal management strategies. Methods This was a cohort study. We reviewed confirmed patients of CNS IMI (January 2004–March 2025) by microbiological (direct microscopy and/or culture) and/or histopathological evidence at our tertiary care hospital. Clinical, demographic and mycological characteristics were analysed and compared. Findings Among 1321 brain abscess/biopsy samples, 127 patients (9.6%) were of fungal origin (adults, 100; paediatrics, 27). The median age was 30 (IQR: 27) years, with male predominance (71.7%). Adults were significantly infected by melanized fungi (p = 0.003). Seventy-four percent of patients had no identifiable underlying immunocompromising condition. The median duration of symptoms was 15 days (IQR: 23 days), including headache (61.4%) and seizures (50.4%). Frequency of fever was significantly higher in infection by melanized fungi (p = 0.02). Frontal lobe involvement was common in paediatric age (OR 0.379, 95% CI 0.141–1.019; p=0.05). Aspergillus spp. (56.3%) and Cladophialophora bantiana (21.36%) were the predominant pathogens. Deniquelata barringtoniae was reported as a human pathogen. Voriconazole (61.4%) and liposomal amphotericin B (28.3%) were the primary antifungals used. Surgical intervention was performed in all patients. Partial excision (66.7% vs 38.0%, OR 0.306, 95% CI 0.125–0.751; p=0.01) and use of liposomal amphotericin B (55.6% vs 21%, OR 0.213, 95% CI 0.087–0.522 p=0.001) were common in paediatric patients. The overall mortality was 30.7%, complete excision was significantly more frequent among survivors than non-survivors (67.0% vs 30.8%; OR 0.218, 95% CI 0.097–0.492; p=0.001). Lack of headache (p = 0.044) and partial excision surgery (p = 0.001) were independently associated with poor outcome. Interpretation We describe a compendium of CNS IMI in patients from India, highlighting distinct clinical patterns and treatment outcomes across age groups and fungal types. This warrants investigation of host and pathogen-related factors in the country. Funding Funding included Department of Science and Technology-Science and Engineering Research Board (DST-SERB), New Delhi, India and Indian Council of Medical Research (ICMR), New Delhi, India.