Fungal brain abscess caused by "Black Mold" (Cladophialophora bantiana) - A case report of successful treatment with an emphasis on how fungal brain abscess may be different from bacterial brain abscess

Background:

Central nervous system infection with Cladophialophora bantiana (Black Mold) is rare. It carries a high mortality rate, that is more than 70%, despite multimodal therapy.

Case Description:

We present a rare case of “black mold” fungal brain abscess that was successfully treated with good patient outcome. The case is unusual because there were two fungal brain abscesses located bilaterally symmetrically in the mesial frontal lobes, and the response to different treatment strategies was well documented by over 25 magnetic resonance imaging (MRI) scans. Initial attempts to treat these lesions by repeated surgical excision and systemic amphotericin B was followed by continued growth rather than resolution. We realized that the application of treatment principles learned from bacterial brain abscess may not transpose intuitively to the treatment of fungal brain abscess. Therefore, a new treatment strategy was adopted that avoided further attempts at resection in favor of long-term oral voriconazole and repeated intracavitary aspiration and instillation of amphotericin B on an outpatient basis. Without further resection, the lesions stabilized and the aspirates eventually sterilized, however, the enhancing capsule never resolved on MRI scans. All treatment was stopped after 1 year. The apparently sterilized lesions have been followed for an additional 3 years without further growth, and the patient remains functionally, intellectually, and behaviorally normal.

Conclusion:

We conclude that, in the case of fungal abscess, it may be preferable to sterilize the lesion in situ rather than attempting to achieve resolution on imaging studies by repeated surgical resection of the capsule which can be counterproductive. This strategy accepts that the capsule may be important to the patient's immune defense against the fungus. Helping that defense barrier with intracapsular and systemic antifungal agents, rather than capsular removal, may be the better strategy for patients in whom early aggressive resection has failed. The basis for the apparent differences in the response of fungal versus bacterial brain abscess to surgical resection is discussed in the light of pathological findings from this and other cases.

[Caesarean section after severe trauma and cardiac arrest - a case report]

A 40 year-old woman with a prominent abdomen was hit by a car on the motorway. The emergency call was "cardiac arrest after multiple trauma in a woman in the late stages of pregnancy". The patient was asystole as indicated by the electrocardiogram 6 minutes after the primary emergency call. Cardiopulmonary resuscitation and endotracheal intubation was performed and a total dose of 3 mg epinephrine was given intravenously. The patient remained asystole. In this preclinical situation the suspected pregnancy could neither be excluded nor confirmed. At least 30 minutes would have been necessary to transfer the patient to the next hospital to perform a caesarean section under controlled conditions. A second physician - trained in obstetrics - was called to perform caesarean section preclinically. In addition, a special ambulance was called to provide sufficient postdelivery care of the neonate. However, the second physician who arrived 18 minutes later was not an obstetrician but also an anaesthesiologist who was trained in neonatal intensive care. At this time - 33 minutes after the first emergency call - the emergency physicians decided to perform a caesarean section immediately. However, the patient was not pregnant. Obviously, the primary emergency call was misleading. The skills of the emergency physicians and the conditions at the site of the emergency have to be weighed carefully against the expected time that is needed to reach the next hospital where a caesarean section can be performed under controlled conditions. In this case, both emergency physicians were anaesthesiologists and they had no doubt that the patient was in the late stages of pregnancy. Due to the prolonged cardiac arrest that did not respond to cardiopulmonary resuscitation both physicians were convinced that immediate preclinical caesarean section represented the only therapeutical option for the unborn patient.

Prevalence of upper extremity neuropathy in a clinical dentist population

When asked about altered sensation in hands or arms, forearms, cervical area or neck, 29 percent of Nebraska dentists surveyed said they felt pain, followed by numbness and tingling. The prevalence suggests the possibility of an occupational concern.