Cerebral aspergillosis in the era of new antifungals: The CEREALS national cohort study Nationwide CEREbral Aspergillosis Lesional study (CEREALS).

BACKGROUND: Cerebral aspergillosis (CA) is a life-threatening disease for which diagnosis and management remain challenging. Detailed analyses from large cohorts are lacking. METHODS: We included 119 cases of proven (n = 54) or probable (n = 65) CA diagnosed between 2006 and 2018 at 20 French hospitals. Data were collected at baseline and during follow-up. Cerebral imaging was reviewed centrally by two neuroradiologists. RESULTS: The most frequent underlying conditions were hematological malignancy (40%) and solid organ transplantation (29%). Galactomannan was detected in the serum of 64% of patients. In 75% of cases, at least one of galactomannan, Aspergillus PCR, and ß-d-glucan was positive in the cerebrospinal fluid. Six-week mortality was 45%. Two distinct patterns of disease were identified according to presumed route of dissemination. Presumed haematogenous dissemination (n = 88) was associated with a higher frequency of impaired consciousness (64%), shorter time to diagnosis, the presence of multiple abscesses (70%), microangiopathy (52%), detection of serum galactomannan (69%) and Aspergillus PCR (68%), and higher six-week mortality (54%). By contrast, contiguous dissemination from the paranasal sinuses (n = 31) was associated with a higher frequency of cranial nerve palsy (65%), evidence of meningitis on cerebral imaging (83%), macrovascular lesions (61%), delayed diagnosis, and lower six-week mortality (30%). In multivariate analysis and in a risk prediction model, haematogenous dissemination, hematological malignancy and the detection of serum galactomannan were associated with higher six-week mortality. CONCLUSION: Distinguishing between hematogenous and contiguous dissemination patterns appears to be critical in the workup for CA, as they are associated with significant differences in clinical presentation and outcome.

Brain abscess in immunocompetent adult patients.

Brain abscess is a focal infection of the brain due to contiguous spread of pathogens following otitis, sinusitis, neurosurgery or traumatic brain injury or through hematogenous dissemination. Classical symptoms consisting of headache, fever, and focal signs may be absent on admission and brain MRI with contrast plays a major role in diagnosis. Initial management consists of stereotactic aspiration for microbiological documentation empirical treatment covering common pathogens, including oral streptococci, staphylococci, anaerobes, and Enterobacteriaceae. De-escalation of antimicrobials based on microbiology is safe only when samples have been processed optimally, or when primary diagnosis is endocarditis. A 6-week combination of third-generation cephalosporin and metronidazole will cure most cases of community-acquired brain abscess in immunocompetent adults. Significant advent in brain imaging, minimally invasive surgery, molecular biology, and antibacterial agents, has dramatically improved the prognosis. Main indicators of outcome include altered mental status at presentation and intraventricular rupture.

Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management.

Neurological complications are frequent in infective endocarditis (IE) and increase morbidity and mortality rates. A wide spectrum of neurological disorders may be observed, including stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Ischemic lesions account for 40% to 50% of IE central nervous system complications. Systematic brain MRI may reveal cerebral abnormalities in up to 80% of patients, including cerebral embolism in 50%, mostly asymptomatic. Neurological complications affect both medical and surgical treatment and should be managed by an experimented multidisciplinary team including cardiologists, neurologists, intensive care specialists, and cardiac surgeons. Oral anticoagulant therapy given to patients presenting with cerebral ischemic lesions should be replaced by unfractionated heparin for at least 2 weeks, with a close monitoring of coagulation tests. Recently published data suggest that after an ischemic stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Surgery should be postponed for 2 to 3 weeks for patients with intracranial hemorrhage. Endovascular treatment is recommended for cerebral mycotic aneurysms, if there is no severe mass effect. Recent data suggests that neurological failure, which is associated with the location and extension of brain injury, is a major determinant for short-term prognosis.

[The association of cardiac involvement and ischemic stroke in Churg Strauss syndrome]. / Accidents ischémiques cérébraux et atteinte cardiaque associés à un syndrome de Churg et Strauss.

In Churg and Strauss syndrome (CSS), three patterns of neurological involvement can be found, including mono or polyneuropathy, encephalopathy and stroke. We report two cases of stroke associated with major hypereosinophilia and cardiac involvement, leading to a diagnosis of CSS. Neurological and general outcome were good under treatment with steroids in combination with cyclophosphamide in one case. Churg and Strauss syndrome must be considered when a stroke is associated with a cardiac involvement and hypereosinophilia.