Endoscopic and intrathecal management of intraventricular fungal infections: a case report of Cladophialophora bantiana and systematic review.

BACKGROUND: Intraventricular fungal infections are rare and associated with high morbidity and mortality. Diagnosis is often delayed due to nonspecific clinical and radiological findings, and treatment is complicated by limited cerebrospinal fluid (CSF) penetration of systemic antifungal agents. Neuroendoscopic visualization and intrathecal antifungal therapy have been reported only sporadically, and standardized management strategies are lacking. CASE PRESENTATION: We report a 75-year-old male who developed a right temporal lobe abscess caused by Cladophialophora bantiana, confirmed by histopathology, culture, and molecular diagnostics. Despite prolonged systemic antifungal therapy, the patient demonstrated clinical and radiographic progression with intraventricular ventriculitis. Neuroendoscopy enabled direct visualization of pigmented intraventricular fungal lesions, targeted biopsy, ventricular lavage, and placement of an Ommaya reservoir, allowing initiation of intrathecal liposomal amphotericin B with serial CSF drug level monitoring and subsequent radiographic stabilization. To contextualize this case, we performed a systematic literature review of intraventricular fungal infections managed with endoscopic procedures and/or intrathecal or intraventricular antifungal therapy, identifying eleven cases involving Aspergillus spp., Cladophialophora bantiana, Mucorales, and other dematiaceous fungi. Management strategies were highly individualized and typically combined surgical intervention, ventricular access devices, systemic antifungals, and local antifungal administration. CONCLUSION: This case report and systematic review highlight neuroendoscopy as a key diagnostic and therapeutic tool in intraventricular fungal infections and underscore the frequent need for intrathecal antifungal therapy when systemic treatment is insufficient. Management remains interdisciplinary and individualized, emphasizing the importance of detailed reporting to inform future treatment strategies. CLINICAL TRIAL NUMBER: Not applicable.