Neuroaspergillosis in an immunocompetent patient

Central nervous system aspergillosis: a series of 14 cases from a general hospital and review of 123 cases from the literature

Central nervous system (CNS) aspergillosis is a highly fatal infection. We review the clinical presentation, diagnosis, and outcome of this infection and present a case series of 14 consecutive patients with CNS aspergillosis admitted to Massachusetts General Hospital (MGH) from 2000 to 2011. We also review 123 cases reported in the literature during that time. We included only proven CNS aspergillosis cases conforming to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal infections. In the MGH case series, neutropenia, hematologic malignancies, autoimmune diseases requiring steroid treatment, and solid organ transplantation were the predominant comorbid conditions. Notably, all MGH patients were immunosuppressed, and more than half (n = 8) had a history of previous brain injury, unrelated to their index hospitalization. For most MGH patients (11 of 14), the lung was the primary focus of aspergillosis, while 2 had paranasal sinus involvement, and 1 had primary Aspergillus discitis. Among reported cases, paranasal sinuses (27.6%) and the lung (26.8%) were the primary foci of infection, whereas 22% of those cases had no obvious primary organ involvement. Although a selection bias should be considered, especially among published cases, our findings suggest that patients who underwent neurosurgery had improved survival, with MGH and literature patients having 25% and 28.6% mortality, respectively, compared to 100% and 60.4%, respectively, among patients who received only medical treatment. Although this was not the case among MGH patients, CNS aspergillosis can affect patients without significant immune suppression, as indicated by the high number of reported immunocompetent cases. In conclusion, mortality among CNS aspergillosis patients remains high, and the infection may be more common among patients with previous brain pathology. When indicated, neurosurgical procedures may improve prognosis.

Lessons from animal studies for the treatment of invasive human infections due to uncommon fungi

Clinical experience in the management of opportunistic infections, especially those caused by less common fungi, is, due to their rarity, very scarce; therefore, the most effective treatments remain unknown. The ever-increasing numbers of fungal infections due to opportunistic fungi have repeatedly proven the limitations of the antifungal armamentarium. Moreover, some of these fungi, such as Fusarium spp. or Scedosporium spp., are innately resistant to almost all the available antifungal drugs, which makes the development of new and effective therapies a high priority. Since it is difficult to conduct randomized clinical trials in these uncommon mycoses, the use of animal models is a good alternative for evaluating new therapies. This is an extensive review of the numerous studies that have used animal models for this purpose against a significant number of less common fungi. A table describing the different studies performed on the efficacy of the different drugs tested is included for each fungal species. In addition, there is a summary table showing the conclusions that can be derived from the analysis of the studies and listing the drugs that showed the best results. Considering the wide variability in the response to the antifungals that the different strains of a given species can show, the table highlights the drugs that showed positive results using at least two parameters for evaluating efficacy against at least two different strains without showing any negative results. These data can be very useful for guiding the treatment of rare infections when there is very little experience or when controversial results exist, or when treatment fails.