3^rd Edition of Infectious Diseases World Conference 2026

Abstract

Postoperative cranial infections following craniotomy are uncommon and are most frequently caused by bacterial pathogens. Fungal infections of the cranial vault are exceedingly rare and pose significant diagnostic and therapeutic challenges due to their indolent presentation and limited evidence guiding management. Candida osteomyelitis of the skull is particularly uncommon and may present weeks to months after neurosurgical intervention.

An 81-year-old man with a history of type 2 diabetes mellitus and hypertension underwent a right frontal craniotomy for evacuation of a subdural hematoma at an outside hospital. He was discharged to a skilled nursing facility for postoperative rehabilitation. Eight weeks later, he presented to our emergency department with localized scalp pain and tenderness at the surgical site, without systemic symptoms. Laboratory evaluation revealed mildly elevated erythrocyte sedimentation rate and C-reactive protein with a normal white blood cell count.

Computed tomography and magnetic resonance imaging of the head demonstrated focal bone erosion underlying the prior craniotomy site, concerning for osteomyelitis. The patient underwent surgical wound revision and debridement. Intraoperative bone cultures grew Candida albicans, while bacterial cultures were negative. Due to baseline QTc prolongation, fluconazole was initially contraindicated, and the patient was treated with intravenous micafungin for six weeks. Management involved a multidisciplinary team including infectious disease and neurosurgery specialists, with plans to transition to prolonged oral fluconazole therapy once QTc normalized. The patient demonstrated interim clinical improvement with resolution of localized pain and normalization of inflammatory markers.

Candida albicans cranial osteomyelitis is an exceptionally rare postoperative complication of craniotomy. Risk factors include diabetes, prolonged antibiotic exposure, and the presence of surgical hardware. Delayed presentation and nonspecific laboratory findings may lead to diagnostic delay. This case highlights the importance of maintaining suspicion for fungal pathogens in delayed postoperative cranial infections and demonstrates the need for individualized antifungal selection when standard therapy is limited by comorbidities such as QT prolongation. Early surgical intervention, prolonged antifungal therapy, and coordinated multidisciplinary care are essential to optimize outcomes in this rare but serious infection.