procedure, the patient developed fever (38°C), lethargy and neck
stiffness. Analysis of ventricular CSF revealed 105 white cells/mm
(90% of the white cells were neutrophils), a glucose level of 23 mg/dL
(glucose level in the blood: 106 mg/dL) and protein of 119 mg/dL.
Microscopic examination of the Gram staining showed yeast and no
other microorganisms. Cultures were positive for C. albican s in three
separate samples. The blood culture was sterile. The patient had been
treated with fluconazole 400 mg intravenously (iv) daily, oxacillin 12 g
iv daily, rifampicin 600 mg iv daily, but meningitis persisted. Twenty
days after the stroke, the patient was admitted to our Infectious
Diseases unit. The external shunt was removed and replaced immedi-
ately, and therapy with AmBisome (3 mg/kg/day) and flucytosine
(150 mg/kg/day) was started. In addition, on days 7–9 of the new
treatment, intraventricular amphotericin B deoxycholate was
injected into the shunt at a dose of 4 mg daily (the shunt was closed for
4 h). Despite this therapy, the patient had a torpid clinical course; his
fluids and clinical condition improved but without complete resolution.
CSF culture was positive until the 7th day of therapy and after this
was negative. Following 23 days of this drug regimen, se rial CSF and
serum samples were taken to check amphotericin B levels. Some
samples were also taken during intraventricular i nfusion. All samples
were stored at –80°C until assay. After 30 days, the patient died as a
result of a second haemorrhagic stroke. Amphotericin B concentrations
in the patient’s CSF and serum samples were analysed by HPLC,
as described by Bekersky et al.
We performed standard curves for
amphotericin B by regression analysis. The peak serum level of
amphotericin B was 15.61 mg/L and the area under the concentration–
time curve (AUC) was 115.5 mg·h/L. Amphotericin B concentrations
in ventricular CSF were between 0.09 and 0.24 mg/L (AUC
3.7 mg·h/L). Concentrations of ventricular amphotericin B taken
after intrathecal administration (range +7, +24 h after intra-shunt
infusion) were between 100.5 and 1.75 mg/L. The concentration of
amphotericin B in lumbar fluid was 0.59 mg/L (the fluid sample was
obtained by single lumbar puncture, 48 h after intra-shunt infusion of
amphotericin B and 22 h after AmBisome iv).
One major concern, for therapy of fungal shunt infections, is CSF
penetration of systemically administered amphotericin B. Currently,
C. albicans is considered susceptible to amphotericin B at a concen-
tration of 1 mg/L (MIC < 1 mg/L).
The minimal drug concentration
achieved at the infection site should be at least equal to the MIC for
the infecting organism, and in vivo, the ratio between the maximum
concentration of the drug (C
) and the MIC value is the best predictor
Conventional amphotericin B deoxycholate is notorious
for its inability to achieve consistently measurable concentrations in
CSF; it ranges from undetectable to no more than 4% of serum con-
A potential strategy for reducing the toxicity and increasing the
therapeutic index of amphotericin B is the use of lipid formulations of
this drug, which allow the administration of a much higher dose.
our case, administration of AmBisome at 3 mg/kg/day did not result
in significantly enhanced amphotericin B concentration in CSF; in
fact a fluid C
of 0.24 is a sub-MIC conc entration, and limited clinical
results were obtained. These data show the po or penetration into CSF
of liposomal amphotericin B at a dose of 3 mg/kg/day (CSF AUC was
equivalent to 3.2% of serum AUC). The intrathecal amphotericin B
therapy, administered only for 3 days in this case, achieved a temporary
elevated concentration in ventricular CSF, but this did not contribute
to the clinical outcome. If CNS penetration is based on C
increased intravenous liposomal amphotericin dosage can be advocated
to treat CNS Candida infections. In clinical situations, the adminis-
tration, at maximal tolerable dosage, of AmBisome (5–10 mg/kg/day)
may provide more effective therapeutic results.
In addition, although
a post-antifungal effect on Candida species was disregarded, it may
have been attributable to amphotericin B and flucytosine,
should be the aim of antimicrobial therapy to increase CSF drug con-
centration above the MIC so that there is a greater possibility of com-
pletely eradicating infection.
There exists a direct relationship between peak concentrations of
amphotericin B in plasma, AUCs and cerebral tissue concentrations.
This correlates directly with greater antifungal efficacy.
azole-resistant Candida shunt infections occur, a high dose of
AmBisome (5–10 mg/kg/day) may be a reasonable option.
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. (1999). Safety and
toxicokinetics of intravenous liposomal amphotericin B (AmBisome) in
2. Ellis, D. (2002). Amphotericin B: spectrum and resistance.
of Antimicrobial Chemotherapy
3. Andes, D., Stamsted, T. & Conklin, R. (2000). Pharmacodynamics
of amphotericin B in a neutropenic-mouse disseminated-candidiasis
Antimicrobial Agents and Chemotherapy
4. Patel, R. (1998). Antifungal agents. Part I. Amphotericin B prepar-
ations and flucytosine.
Mayo Clinic Procceedings
5. Walsh, T. J., Goodman, J. L., Pappas, P.
. (2001). Safety, tol-
erance and pharmacokinetics of high-dose liposomal amphotericin
B (AmBisome) in patients infected with
species and other
filamentous fungi: maximum tolerated dose study.
6. Turnidge, J. D., Gudmundsson, S., Vogelman, B.
. (1994). The
postantibiotic effect of antifungal agents against common pathogenic
Journal of Antimicrobial Chemotherapy
Journal of Antimicrobial Chemotherapy
Advance Access publication 12 November 2003
Vitamin C and SARS coronavirus
Department of Public Health, University of Helsinki, Helsinki,
Keywords: ascorbic acid, pneumonia, severe acute respiratory
*Tel: +359-0-191-27573; Fax: +358-0-191-2757 0;
Recently, a new coronavirus was identified as the cause of the severe
acute respiratory syndrome (SARS).
In the absence of a specific
treatment for SARS, the possibility that vitamin C may show non-
specific effects on severe viral respiratory tract infections should be
considered. There are numerous reports indicating that vitamin C
may affect the immune system,
for example the function of phago-
cytes, transformation of T lymphocytes and production of interferon.
In particular, vitamin C increased the resistance of chick embryo
tracheal organ cultures to infection caused by an avian coronavirus.
Studies in animals found that vitamin C modifies susceptibility to
various bacterial and viral infections,
for example protecting broiler
chicks against an avian coronavirus.
Placebo-controlled trials have
shown quite consistently that the duration and severity of common
cold episodes are reduced in the vitamin C groups,
viral respiratory infections in humans are affected by vitamin C levels.
There is also evidence indicating that vitamin C may affect pneumonia.
In particular, three controlled trials with human subjects reported a
significantly lower incidence of pneumonia in vitamin C-supplemented
suggesting that vitamin C may affect susceptibility to lower
respiratory tract infections under certain conditions. The possibility
that vitamin C affects severe viral respiratory tract infections would
seem to warrant further study, especially in light of the recent SARS
1. Holmes, K. V. (2003). SARS-associated coronavirus.
Journal of Medicine
2. Leibovitz, B. & Siegel, B. V. (1981). Ascorbic acid and the immune
Advances in Experimental Medicine and Biology
3. Hemilä, H. & Douglas, R. M. (1999). Vitamin C and acute respiratory
International Journal of Tuberculosis and Lung Diseases
4. Atherton, J. G., Kratzing, C. C. & Fisher, A. (1978). The effect of
ascorbic acid on infection of chick-embryo ciliated tracheal organ cultures
Archives of Virology
5. Davelaar, F. G. & Bos, J. (1992). Ascorbic acid and infectious
bronchitis infections in broilers.
6. Hemilä, H. (1997). Vitamin C intake and susceptibility to pneumonia.
Pediatric Infectious Diseases Journal