Longitudinally extensive posterolateral myelitis revealing invasive CNS aspergillosis in an immunocompetent patient.

BACKGROUND: Fungal infections of the central nervous system usually affect immunocompromised patients. Primary Aspergillus myelitis has never been described. REPORT: A 45-year-old immunocompetent male with subacute paraplegia was treated for inflammatory myelitis before clinical deterioration requiring mechanical ventilation. Purulent meningitis preceded the formation of a paraspinal nodule biopsied by neurosurgery. Histopathological analysis revealed the presence of fungal hyphae, and polymerase chain reaction was positive for Aspergillus fumigatus. No cause of immunodeficiency was identified in this patient. DISCUSSION: Primary Aspergillus myelitis may be confused with inflammatory myelitis and should be considered even in the absence of apparent immunosuppression.

Bilateral Cerebral Mucormycosis in an Immunocompetent Female.

Background: Mucormycosis is a serious angioinvasive fungal infection. Immunocompromised patients are more likely to be susceptible to mucormycosis than immunocompetent individuals. Cerebral mucormycosis has been reported, but cases have primarily been unilateral. We report a case of bilateral cerebral mucormycosis in an immunocompetent patient. Case Report: A 37-year-old female with no significant medical history was transferred to our tertiary center after cerebrospinal fluid profile following a lumbar puncture at an outside hospital suggested bacterial meningitis. Computed tomography of the head revealed hypodensity and cerebral edema in the left basal ganglia, and magnetic resonance imaging (MRI) brain showed increased T2 signal and mass-like configuration centered in the left basal ganglia. During her hospital stay, she had neurologic decompensation with respiratory failure. She was intubated and placed on mechanical ventilation. Repeat MRI brain revealed evolving cerebral edema signal and interval development of progression across the midline involving the right basal ganglia. Because of the aggressive nature of the lesion and cerebral edema, she underwent a biopsy with placement of an external ventricular drain. Despite medical and surgical interventions, she neurologically worsened and died. Histopathologic evaluation of the biopsied lesion revealed numerous fungal hyphae consistent with mucormycosis. Conclusion: Our patient was not immunocompromised, and this case highlights the clinical challenges in initiating immunosuppressive therapy in a patient with rapidly progressive central nervous system disease.

Central nervous system infection: imaging findings suggestive of a fungus as the cause.

Fungal infections of the central nervous system (CNS) are rare. However, because of the increase in the number of immunocompromised individuals, they have been gaining prominence in the differential diagnosis of CNS infections. Imaging techniques are sensitive for detecting and localizing an abnormality, in many cases allowing the origin of a lesion to be categorized as infectious, inflammatory, neoplastic, or vascular. This essay illustrates the magnetic resonance imaging and computed tomography findings of the most common fungal infections of the CNS, based on the experience of the Radiology Department of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, RS, Brazil.

As infecções fúngicas do sistema nervoso central (SNC) são raras, entretanto, com o aumento no número de indivíduos imunocomprometidos elas têm ganhado destaque no diagnóstico diferencial de infecções no SNC. As atuais técnicas de imagem são sensíveis para detectar uma anormalidade, localizá-la, e em muitos casos categorizar a lesão como de origem infecciosa e/ou inflamatória, neoplásica ou vascular. Este ensaio ilustra os achados de ressonância magnética e tomografia computadorizada mais comuns nas infecções fúngicas do SNC baseadas na experiência do Serviço de Radiologia do Hospital de Clínicas de Porto Alegre.

Central nervous system infection: imaging findings suggestive of a fungus as the cause / Infecção do sistema nervoso central: os achados de imagem sugestivos de fungo como causa

Abstract Fungal infections of the central nervous system (CNS) are rare. However, because of the increase in the number of immunocompromised individuals, they have been gaining prominence in the differential diagnosis of CNS infections. Imaging techniques are sensitive for detecting and localizing an abnormality, in many cases allowing the origin of a lesion to be categorized as infectious, inflammatory, neoplastic, or vascular. This essay illustrates the magnetic resonance imaging and computed tomography findings of the most common fungal infections of the CNS, based on the experience of the Radiology Department of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, RS, Brazil.

Resumo As infecções fúngicas do sistema nervoso central (SNC) são raras, entretanto, com o aumento no número de indivíduos imunocomprometidos elas têm ganhado destaque no diagnóstico diferencial de infecções no SNC. As atuais técnicas de imagem são sensíveis para detectar uma anormalidade, localizá-la, e em muitos casos categorizar a lesão como de origem infecciosa e/ou inflamatória, neoplásica ou vascular. Este ensaio ilustra os achados de ressonância magnética e tomografia computadorizada mais comuns nas infecções fúngicas do SNC baseadas na experiência do Serviço de Radiologia do Hospital de Clínicas de Porto Alegre.

Central nervous system candidiasis beyond neonates: Lessons from a nationwide study.

Though candidiasis is the most frequent invasive fungal infection, Candida spp. central nervous system (CNS) infections are rare but severe. To further describe clinico-patho-radiological presentations of this entity, we report a retrospective study from January 2005 to December 2018 including patients aged ≥ 28 days with proven or probable CNS candidiasis in France. Twenty-four patients were included. Seventeen patients (70%) had CNS localization secondary to disseminated candidiasis (10 with hematologic malignancies [HM]; the seven other patients had infective endocarditis [IE]). Among patients with HM, seven previously had lumbar puncture for intrathecal chemotherapy, the three others had IE. Among patients with disseminated infection, magnetic resonance imaging (MRI) evidenced meningitis (17%), micro-abscesses (58%), or vascular complications (67%). Seven patients (30%) had isolated CNS involvement related to neurosurgery (n = 2), CARD9 deficiency (n = 2), intravenous drug use, diabetes mellitus, or no identified predisposing condition (n = 1 each). All evaluated patients with isolated CNS involvement had meningitis on cerebrospinal fluid (CSF) and intracranial hypertension. For the latter patients, MRI evidenced meningitis (71%) or abscesses (57%). Among all patients, cerebrospinal fluid (CSF) culture grew Candida spp. in 31% of cases. CSF ßDGlucan or mannan Ag were positive in respectively 86% and 80% of cases. Mortality attributed to CNS candidiasis was 42%: 53% in case of disseminated infection (70% for HM) and 14% in case of localized infection. CNS candidiasis are isolated or occur during disseminated infection in patients with HM and lumbar puncture for intrathecal chemotherapy or during IE. Clinical, radiological finding and outcome highly vary according to CNS localized versus disseminated candidiasis. LAY SUMMARY: Candida is a yeast and is the most common cause of fungal infections worldwide. Candida central nervous system (CNS) infections are rare, severe, and poorly described. We report a retrospective study from January 2005 to December 2018 including patients aged ≥ 28 days with proven or probable CNS candidiasis in France. Twenty-four patients were included (14 men, median age 51 years). Seventeen patients had CNS localization secondary to disseminated candidiasis from blood to CNS (10 with hematologic malignancies [HM], the seven other patients had infective endocarditis [IE]). Seven patients had isolated CNS involvement related to neurosurgery (n = 2), CARD9 deficiency (n = 2), intravenous drug use (n = 1), diabetes mellitus (n = 1), or no identified risk factor (n = 1).During Candida CNS infections, brain lesions were meningitis abscesses or vascular complications. Cerebrospinal fluid (CSF) culture grew Candida spp. in 31% of cases. Forty-two percent of patients died from infection: 53% in case of disseminated infection (70% for HM) and 14% in case of localized infection.

Multisystemic fusariosis with fulminant evolution

Abstract This report presents the case of a 13-year-old female patient with history of acute myeloid leukemia, who, after a bone marrow transplant, began to vomit and experienced rapidly progressive deterioration of consciousness, in addition to disseminated erythematous-violaceous macules, and some blisters with hemorrhagic content inside. Skin biopsy evidenced intravascular filamentous structures. A blood culture confirmed the presence of Fusarium oxysporum. Intravenous treatment with voriconazole was initiated. The patient evolved unfavorably with multiple necrotic skin lesions, ischemic brain lesions, and death.

Multisystemic fusariosis with fulminant evolution.

This report presents the case of a 13-year-old female patient with history of acute myeloid leukemia, who, after a bone marrow transplant, began to vomit and experienced rapidly progressive deterioration of consciousness, in addition to disseminated erythematous-violaceous macules, and some blisters with hemorrhagic content inside. Skin biopsy evidenced intravascular filamentous structures. A blood culture confirmed the presence of Fusarium oxysporum. Intravenous treatment with voriconazole was initiated. The patient evolved unfavorably with multiple necrotic skin lesions, ischemic brain lesions, and death.

Cavernous Thrombophlebitis Secondary to Cavernous Internal Carotid Mycotic Aneurysm.

We report a case of a 22-year-old male with a history of intravenous drug use presenting with cavernous sinus syndrome secondary to cavernous thrombophlebitis. The source of the thrombophlebitis was from a mycotic aneurysm in the setting of fungal endocarditis. With antifungal therapy and aortic valve replacement, the patient had full resolution of cranial nerve deficits. Descriptions of mycotic aneurysms of the cavernous portion of the internal carotid artery are limited to case reports and case series. Most have been nonendocarditic in etiology with poor prognosis. We present a unique case with endocarditic etiology and an excellent prognosis.

[Advance study of rhinocerebralmucormycosis].

Mucormycosis is a rare, rapidly progressive life threatening opportunistic fungal infection, with rhinocerebral mucormycosis being the most common type. Rhinocerebral mucormycosis usually presents symptoms similar to sinusitis and orbital cellulitis during its early stage,which often leads to a misdiagnosis at the very beginning,and progresses rapidly to endophthalmitis,blindness,sclera perforation, eyeball atrophy, and even gets the central nervous system involved, thus leading to death. Mucormycosis is particularly common in patients with poor glycemic control, ketoacidosis and immunosuppression. The purpose of this review is to highlight the predisposing factors, infection pathway, pathogenesis, clinical presentations, diagnosis, and management of rhinocerebral mucormycosis, hence further promote the early diagnosis and immediate treatment of the disease. (Chin J Ophthalmol,2019,55:629-633).

Diagnosing Ring-Enhancing Lesions in the Brain of a Patient With AIDS Without Brain Biopsy: A Case of Central Nervous System Histoplasmoma.

We report a case of a Puerto Rican male with advanced AIDS who presented with multiple falls and pancytopenia. Magnetic resonance imaging (MRI) of the brain, as initial workup, revealed 2 ring-enhancing brain lesions. Initial cerebrospinal fluid analysis revealed minimal cells, mildly elevated protein, and no organism seen on gram stain. Due to prohibitive thrombocytopenia, brain biopsy was deferred. He had neither clinical nor radiographic improvement despite empiric therapy for both toxoplasmosis and bacterial abscesses. Indicated by pancytopenia, bone marrow (BM) aspiration was performed. Culture of BM aspirate grew Histoplasma capsulatum. Urine histoplasma antigen was markedly elevated. He was treated with liposomal amphotericin B (LamB) for progressive disseminated histoplasmosis with probable central nervous system involvement. Cerebrospinal fluid histoplasma antigen obtained after 2 months of LamB was detected. After prolonged course of LamB, he took itraconazole. Brain MRI at 7-month follow-up revealed significant improvement from baseline study.

Direct Invasion of the Optic Nerves, Chiasm, and Tracts by Cryptococcus neoformans in an Immunocompetent Host.

Cryptococcus spp is a common fungal infection and frequent cause of meningitis in immunocompromised patients; however, immunocompetent patients are also at risk of infection. Visual loss often occurs via elevated intracranial hypertension but can rarely occur through direct optic nerve, chiasm, or tract invasion. We report a case of a 38-year-old woman who presented with decreased acuity in both eyes. She had generalized visual field constriction in the right eye and temporal hemianopsia in the left eye. Magnetic resonance imaging of the brain and orbits showed multiple areas of ill-defined enhancement in the optic chiasm and tracts as well as in the diaphragmatic sella, prepontine and interpeduncular cisterns, and along cranial nerves VI, VII, and VIII bilaterally. Initial cerebrospinal fluid (CSF) showed 34 white blood cells, hypoglycorrhachia, and negative cryptococcal antigen and bacterial and fungal cultures. A transphenoidal biopsy of the dura and pituitary gland was unremarkable. Empiric steroids resulted in marked improvement in visual acuity in both eyes, but while tapering steroids, she developed rapid visual loss bilaterally. Repeat CSF performed 6 weeks later demonstrated a cryptococcal antigen titer of 1:512. Retroactive staining of the pituitary biopsy was positive for mucicarmine, a component of the polysaccharide capsule of Cryptococcus spp. After induction therapy with amphotericin B and flucytosine and 1 year of fluconazole, her visual acuity was 20/20 in both eyes. In summary, Cryptococcus can affect immunocompetent patients and often presents with insidious, chronic meningitis. Visual loss is common in cryptococcal meningitis but usually results from fulminant papilledema related to elevated intracranial pressure. In rare cases, direct nerve or chiasm infiltration by the fungus results in vision loss.

Diagnosis and treatment of 3 patients of intracranial fungai granulomas / 中华神经科杂志

Objective To examine clinical features, neuroimaging presentation and treatment of intracranial fungal granulomas (ICFG) in order to improve the accuracy rates of diagnosis and cure. Methods Three pathologically proven cases with ICFG were retrospectively analyzed. Cases of ICFG reported in literature were also summarized. Results Among the 3 patients with ICFG, 1 patient had a history of head trauma and craniotomy and 1 had a history of type 2 diabetes mellitus and a long history of exposure to doves. In all 3 patients, the symptoms started with headache and vomiting, accompanied by low-grade fever, convulsion, and cranial nerve deficits. Intracranial mass lesion was revealed on brain computed tomography (CT) scan and (or) magnetic resonance imaging (MRI) with or without intravenous contrast. CT scan showed low-density lesions and granulations with ring and homogenous enhancement, indicating fungal abscesses. MRI in all 3 cases showed one or multiple circumscribed intracranial space-occupying lesion, with ring, heterogeneous contrast enhancement and perilesional edema. The treatments were initiated with craniotomy and surgical resection of granulations followed by intravenous injection of amphotericin B (AMB) combined with fluconazole. The daily administration of AMB was increased gradually from 0.25-1.50 mg/kg and the total dosage of 2-4 g should be achieved within 3 months. The combination therapy with fluconazole (400 mg/d ) was also given by intravenous injection. To increase penetration into cerebrospinal fluid, intrathecal injection of AMB had also been given at the maximum dosage of 1 mg every time, twice a week. Two patients were administered fluconazole (200 mg/d ) orally for 3, 6 months consecutively after completing the combination therapy of AMB with fluconazole, while the other patient refused continuous antifungal treatment 1 month postoperatively. All 3 patients were followed up for a period between 3, 24, 48 months. The 2 patients that completed full antifungal treatment were cured without recurrence. The other patient had improved transiently after operation but died after 3 months. Conclusions Because no distinct chnical and neuroimaging features are presented in ICFG, it is difficult to diagnose preoperatively. Indications for surgery include diagnosis, relief mass effect and increase efficiency of drug treatment. Use of appropriate and completed antifungal treatment decreases mortality. The treatment requires continued and long-term administration of antifungal medication to prevent relapses, whether granulomas are totally removed or not.

Paracoccidioidomicose com comprometimento do sistema nervoso central: revisão de literatura / Paracoccidioidomycose with central nervous systeminvolvement: review of the literature

A Paracoccidioidomicose (PCM), considerada a micose profunda mais importante da América Latina, é causada pelo fungo Paracoccidioides brasiliensis. O Brasil concentra o maior número de casos, especialmente na região Sudeste. A doença pode acometer inúmeros órgãos como os pulmões, a pele, as mucosas. O envolvimento do sistema nervoso central (SNC) ocorre em aproximadamente 10% dos casos e sua incidência pode ser subestimada devido à ocorrência de apresentações assintomáticas, avaliação neurológica inadequada, falta de testes específicos de neuroimagem e baixa freqüência de estudo do SNC em necrópsias. As formas de apresentação são a meníngea/meningoencefálica, raras, e a pseudotumoral, mais freqüente. A sintomatologia é diversa, variando conforme a localização das lesões, e não específica. Os métodos de neuroimagem são considerados essenciais no auxílio diagnóstico, o exame do líquor é pouco específico e métodos sorológicos ainda têm valor limitado, sendo usados principalmente para seguimento da resposta ao tratamento, cuja primeira escolha, para qualquer forma de apresentação, é a associação sulfametoxazoltrimetoprim. Reserva-se a anfotericina B para os casos de resistência ou intolerância às sulfonamidas. Uma alternativa são o azólicos, como o itraconazol ou o fluconazol. Ainda não se estabeleceram parâmetros confiáveis para indicar o momento seguro de interrupção do tratamento ou para sua reintrodução precoce em caso de recidivas. A PCM deve ter ser considerada no diagnóstico diferencial dos processos meningoencefalíticos e expansivos do SNC, dependendo de um alto grau de suspeição do médico a fim de se estabelecer o tratamento precoce e evitar o surgimento de seqüelas incapacitantes.

Paracoccidioidomycosis (PCM), considered the most important systemic mycosis in Latin America, is caused by the fungus Paracoccidioides brasiliensis. Brazil has the greatest amount of reported cases, especially in the Southeastern region. The disease can affect several sites as the lungs, the skin and the mucous membranes. Central nervous system (CNS) involvement occurs approximately in 10% of the cases, and its incidence can be underestimated due to the occurrence of asymptomatic cases, inadequate neurological evaluation, no specific neuroimagingexams, and low frequency of SNC investigation in autopsies. Neuroparacoccidioidomycosis (NPCM) comprises meningeal form, which is rare, and the most frequent pseudotumoral one. The symptoms are varied, depending on the location of the lesions, and not specific. Neuroimaging methods are considered essential for the diagnosis. Examination of the cerebral spinal fluid is not specific and serological methods still have limited value, being used mainly in the evaluation of treatment response. The first choice for PCM treatment is the association sulfamethoxazoletrimethoprim. Amphotericin B is reserved for the cases of resistance or intolerance to sulfonamides. Alternatively there are itraconazole or fluconazole. No trustworthy parameters were yet established to indicate the ideal moment for interrupting drug treatment or for its early reintroduction. NPCM must be considered in the differential diagnosis of the meningeal and the tumoral/expansive processes of the CNS, depending on a high suspicion level of the physician in order to establish the early treatment and to avoid the development of disabling sequelae.