Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation

CONTEXT

Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described.

CASE REPORT

A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death.

CONCLUSIONS

Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Occupational CNS aspergillosis in an immunocompetent individual a diagnostic challange

INTRODUCTION

Immunocompetent individuals are rarely affected by Aspergillus species and its prime importance lies in immunocompromised patients where it can cause disease, ranging from primarily pulmonary infections to dissemination anywhere in the body. Invasive aspergillosis (IA) occurs in patients with risk factors including prolonged neutropenia, neutrophil dysfunction, patient on cytotoxic drugs, steroid therapy, hematological malignancy, AIDS or in patients with bone marrow transplantation. A recently documented risk factor for IA is the exposure to environmental aspergillus spores at construction sites which makes it an important public health issue. We report here a case of primary CNS aspergillosis in an immunocompetent person who was initially diagnosed as a case of meningioma, and had a history of working in an area with excessive ongoing construction. He had no other primary focus of infection anywhere in the body. He was timely diagnosed and broad spectrum antifungals were started immediately.

MATERIAL AND METHODS

The brain biopsy and pus sampleas were subjected to direct microscopy using KOH mount and lactophenol cotton blue (LPCB) stain and culture on Sabourad's Dextrose Agar in Microbiology laboratory. Later patient was started on fluconazole and caspofungin.

RESULTS

Thin, hyaline, septate hyphae on direct microscopy and growth of Aspergillus flavus on SDA culture were observed. The patient improved only with antifungals, without surgery.

DISCUSSION

This case study highlights the importance of keeping the differential diagnosis of Aspergillus spp. in mind even in individuals with no immunodeficiency. The immunocompetent individuals have better prognosis and if timely diagnosed, can be treated even without surgery. The prevalence of aspergillus spores at construction and demolition sites makes it an important public health issue, hence precautions must be advocated at these sites.

First fatal cerebral phaeohyphomycosis due to Rhinocladiella mackenziei in Iran, based on ITS rDNA

Black yeast-like fungi and relatives as agents of cerebral phaeohyphomycosis are often encountered in human fatal brain abscesses and lead to almost 100% mortality despite the application of antifungal and surgical therapy. We report to our knowledge the first case of brain infection due to Rhinocladiella mackenziei in a 54-year-old immunocompetent male in Iran where R. mackenziei has not been reported previously. The initial diagnosis was brain fungal infection because of pigmented, irregular, branched, septated hyphae based on histopathological staining. The patient was treated with intravenous amphotericin B deoxycholate (0.5mg/kg/day) combined with oral itraconazole (200mg twice daily), nevertheless, his neurological function deteriorated rapidly and ultimately the patient died due to respiratory failure later two weeks. R. mackenziei was identified based on the sequencing of internal transcribed spacer (ITS rDNA region) (KJ140287). Therefore, considerable attention for this life-threatening infection is highly recommended.

[Non-obstructive hydrocephalus internus with a rare pathogenesis--mucormycosis]

The case of a 9-year-old boy is presented in this article who developed a rare fungal infection of central nervous system. The histopathologic examination has revealed mucormycosis. The diagnosis wasn't confirmed microbiologically as the culture and PCR were negativ. After the iv administered Amphotericin B lipid complex the MR images of the brain have improved. The mucormycosis classically develops in immunodeficient patients and presents an acute, fulminant, mostly lethal infection. This case is very unusual, because the chronic, isolated CNS mucormycosis has slowly developed in immuncompetent patient and only one symptom was the long existing headache. The aim of this paper is reporting the case history and to find out the possible way of infection.

Rhinocerebral zygomycosis in a young girl undergoing allogeneic stem cell transplantation for severe aplastic anaemia

We report on a 10-year-old girl with severe aplastic anaemia who developed rhinocerebral infection caused by Absidia corymbifera and a possible co-infection caused by Alternaria alternata. Despite prolonged neutropenia, therapy with liposomal amphotericin B and posaconazole improved the clinical condition. Subsequently, the girl underwent allogeneic haematopoietic stem cell transplantation (HSCT) for the underlying disease, but the fungal infection remained under control with the antifungal treatment. No severe side effect of the antifungal drugs was noted. Unfortunately, the girl died 5 months after HSCT due to disseminated adenovirus infection.

Neonatal fungal ventriculitis

Intracranial fungal infection is increasingly seen in the neonatal intensive care setting, with premature infants at greatest risk. We report a case of fungal ventriculitis in an extremely low birth weight neonate due to Candida species. Cranial sonographic examination revealed extensive ventricular stranding with complete resolution in response to therapy.

Bilateral mycotic cerebral abscess due to aspergillosis--a case report

Aspergillosis of central nervous system is an uncommon infection mainly occurring in immunocompromised patient. It may be present in several forms: abscess, meningitis, mycotic aneurysm, infarction and in tumoral form. Here we report a case of cerebral aspergillosis presenting as bilateral frontal lobe abscess without evidence of any underlying systemic disorder or extracranial disease.

Invasive aspergillosis of the central nervous system after allogeneic stem cell transplantation

Central nervous system aspergillosis is a rare infectious complication in patients submitted to allogeneic stem cell transplantation. When it arises, this infection appears early post-transplant and most patients present with multiple central nervous system lesions. We report the clinical case of a 52 year old woman with IgGk multiple myeloma in relapse after a matched related allogeneic bone marrow transplant, who presented with a single large central nervous system Aspergillus lesion 11 months post-transplant in the setting of acute graft vs. host disease developing after the infusion of donor leucocytes. Although liposomal amphotericin B was promptly instituted, the patient died 1 week after the diagnosis.

Fungal CNS infections in patients with hematologic malignancy

Various fungal agents can cause CNS infections. CNS fungal infections may present as a mass (i.e., brain abscess) typically in the course of aspergillosis or zygomycosis, or may primarily involve the meninges (i.e., meningitis), as can be observed in patients with candidiasis or cryptococcosis. Most commonly, fungal brain abscesses are due to aspergillosis. CNS aspergillosis is observed particularly in acute leukemia and allogeneic hemopoietic stem cell transplantation patients. Usually, aspergillosis is localized in the lungs and secondarily spreads to the brain; only in few cases does it develop as solitary localization of CNS. In these conditions, diagnosis is very difficult because signs and symptoms can be completely aspecific. Diagnosis can often be performed only through aggressive procedures (i.e., stereotactic puncture). Zygomycetes are the second most frequent cause of brain abscesses. CNS involvement is higher than in the course of invasive aspergillosis, and this fungal complication is also characterized by a high mortality rate. In vitro and in vivo studies demonstrated that only posaconazole and lipid formulations of amphotericin B present some possibility of success in the treatment of zygomycosis, but the pharmacologic approach should always be associated with surgery. Among molds, other agents (i.e., Fusarium and Scedosporium) may also be responsible for fungal abscess. More rarely during the course of a hematologic malignancy, a meningeal candidiasis or cryptococcosis may be observed. This review mainly focuses on the epidemiology, clinical manifestations, diagnosis and management strategies of all cases of CNS fungal infections in hematologic patients.

Neuroimaging of infections

Neuroimaging plays a crucial role in the diagnosis and therapeutic decision making in infectious diseases of the nervous system. The review summarizes imaging findings and recent advances in the diagnosis of pyogenic brain abscess, ventriculitis, viral disease including exotic and emergent viruses, and opportunistic disease. For each condition, the ensuing therapeutic steps are presented. In cases of uncomplicated meningitis, cranial computed tomography (CT) appears to be sufficient for clinical management to exclude acute brain edema, hydrocephalus, and pathology of the base of skull. Magnetic resonance imaging (MRI) is superior in depicting complications like sub-/epidural empyema and vasculitic complications notably on FLAIR (fluid-attenuated inversion recovery)-weighted images. The newer technique of diffusion-weighted imaging (DWI) shows early parenchymal complications of meningitis earlier and with more clarity and is of help in differentiation of pyogenic abscess (PA) from ring enhancing lesions of other etiology. Proton magnetic resonance spectroscopy (PMRS) seems to produce specific peak patterns in cases of abscess. The presence of lactate cytosolic amino acids and absence of choline seems to indicate PA. Also in cases of suspected opportunistic infection due to toxoplasma DWI may be of help in the differentiation from lymphoma, showing no restriction of water diffusion. In patients with herpes simplex and more exotic viruses like West Nile and Murray Valley virus DWI allows earlier lesion detection and therapeutic intervention with virustatic drugs.

Diffusion-weighted imaging of fungal cerebral infection

BACKGROUND AND PURPOSE

Diffusion-weighted imaging (DWI) is useful in diagnosing bacterial brain abscesses, but DWI features of fungal brain abscesses have not been characterized. Because fungal abscesses are not purulent, we hypothesized that their DWI characteristics are distinct from those of bacterial abscesses.

METHODS

We reviewed clinical, neuropathologic and neuroimaging findings of patients with fungal brain infections due to Aspergillus (n = 6), Rhizopus (n = 1), or Scedosporium (n = 1) species. DWI and apparent diffusion coefficient (ADC) maps were obtained before definitive diagnosis and antifungal therapy. ADC ratios (lesion/contralateral white matter) were calculated.

RESULTS

Two patients had a rapidly progressive, fatal course, with cerebritis and acute inflammation; fungal organisms were largely restricted to vessels. Lesions were predominantly nonenhancing and had heterogeneous foci of restricted diffusion. Six patients with subacute neurologic presentations had acute or chronic inflammation, capsule formation, focal necrosis, and fungal organisms disseminated throughout the lesion. Their abscesses were ring enhancing. In five, lesions had restricted diffusion in the central nonenhancing portions. The sixth patient had a lesion with a peripheral rim of restricted diffusion but elevated central diffusion; histopathology showed early abscess formation. Mean ADC for all lesions was 0.33 +/- 0.06 x 10(-3) mm(2)/s, with an average ADC ratio of 0.43.

CONCLUSION

Fungal cerebral abscesses may have central restricted diffusion similar to that of bacterial abscesses but with histologic features of acute or chronic inflammation and necrosis rather than suppuration. Altered water diffusion in these lesions likely reflects highly proteinaceous fluid and cellular infiltration.

Instrumentation in patients with spinal infection

Object

Placement of instrumentation in the setting of a spinal infection has always been controversial. Although the use of allograft and autograft bone has been accepted as safe, demonstrations of the effectiveness of titanium have been speculative, based on several retrospective reviews. The authors' goal in this study was to demonstrate the effectiveness of instrumentation in the setting of a spinal infection by retrospectively reviewing their cases over the last 4 years and searching the literature regarding instrumentation in patients with pyogenic spinal infections.

Methods

The authors conducted a retrospective review of their cumulative data on spinal infections. Diagnosis was based on subjective and objective clinical findings, along with radiographic and laboratory evaluation of infection and mechanical stability. Patients with medically managed disease and those who did not receive instrumentation were eliminated from this review.

Of 105 patients with spinal infections who were admitted to the neurosurgical service between January 2000 and June 2004, 30 underwent surgical debridement necessitating spinal instrumentation. There were 17 women and 13 men in this group ranging from 28 to 86 years of age. Follow-up duration ranged from 3 to 54 months. There was one death, which occurred 3 months postsurgery. In three patients a deep wound infection developed, necessitating intervention, and two patients experienced a graft expulsion. Twenty-nine patients went on to demonstrate adequate fusion based on follow-up neuroimaging studies.

Conclusions

The goal of neurosurgical intervention in the setting of spinal infection is to obtain an organism culture and the debridement of infection while maintaining neurological and mechanical stability. The authors demonstrate the effectiveness of radical debridement of infected bone and placement of instrumentation in patients with spinal infections.

Brain abscess caused by Cladophialophora (Xylohypha) bantiana in a renal transplant patient

Infectious disease is the most significant cause of morbidity and mortality in allotransplantation because of heavy immunosuppression. Brain abscesses caused by melanized fungi have been found occasionally and are an example of this complication. In this paper, we describe a case in a 61-year-old black man, who received a cadaveric kidney transplantation in December 1993, followed by triple therapy with cyclosporine, azathioprine, and prednisone. The patient developed right hemiparesis at the beginning of April 1998. A computed tomography scan showed a mass in the left parieto-temporal region of the brain. The patient underwent surgery and a brown-colored encapsulated brain abscess was resected. Histology of the tissue revealed a large number of pigmented fungal hyphae. Culture in a Sabouraud dextrose medium with cyclohexamide and chloramphenicol at 25 degrees C resulted in the growth of dark-green colonies. The fungus identified was Cladophialophora bantiana, based on characteristic microscopic features and on growth at 40 degrees C. The abscess recurred in spite of treatment with fluconazole. The patient was submitted to a second brain surgical procedure and was treated with amphotericin B in addition to fluconazole. Ten days later the patient's blood cultures became positive for Escherichia coli. After 3 days the patient died due to septic shock.

Management of CNS mucormycosis in the pediatric patient

Rhinocerebral mucormycosis (RM) is a rare, rapidly progressive disorder caused by fungi from the Mucoraceae family. With extensive central nervous system involvement, this disease is uniformly fatal within weeks. Mucormycosis normally presents in poorly controlled diabetics, intravenous drug abusers and immunocompromised patients. Many have advocated radical surgical resection (i.e. exenteration of the cavernous sinus with carotid sacrifice and en bloc resection) with administration of amphotericin B. We present a case of mucormycosis involving the paranasal sinuses and cranial base in a pediatric patient who experienced long-term survival with a more limited resection. We also present a review of the relevant literature. A 14-year-old diabetic male presented with RM with involvement of the bilateral frontal lobes, right basal ganglia and temporal lobe. Additionally, there was involvement of the sphenoid sinus and right cavernous sinus with extension into the posterior fossa along the course of the trigeminal nerve and encasement with narrowing of the right carotid artery. The patient underwent sinus endoscopy with debridement of necrotic fungal tissue and bone. This was followed by craniotomy with evacuation of bifrontal, right temporal and basal ganglia abscesses in such a way that all abscess cavities communicated. An Ommaya reservoir was placed into the largest cavity. The patient continued to receive intrathecal and intravenous antibiotics as well as hyperbaric oxygen therapy. The patient was clinically and radiographically free of disease 1 year after diagnosis. While invasive RM is generally a fatal disease, this rare disorder can be treated successfully without radical resection, particularly if multimodality treatment options are implemented.

Central nervous system paracoccidioidomycosis: imaging findings in 17 cases

PURPOSE

To quantify the imaging findings of 17 patients with central nervous system (CNS) paracoccidioidomycosis.

METHOD

Retrospective analysis of the clinical data, films, and laboratory findings of 17 patients with CNS paracoccidioidomycosis. The clinical data were obtained by medical records review. Plain chest films, cranial computed tomography scans (CT), and serum and liquor analysis were evaluated.

RESULTS

All the patients were male, with a mean age of 46.5 years. Headache and hemiparesis were the most frequent symptoms. The head CT scans revealed two or more granulomas in 53% of the cases, frequently confined to the parietal lobes (35%) and cerebellar hemispheres (35%). The lesions were hypodense (53%) and irregular (76%) and showed ring-like contrast enhancement (94%). Perilesional edema was seen in 82% of the patients, and hydrocephalus was seen in 41%.

CONCLUSION

Although CNS paracoccidioidomycosis might represent a suspicious lesion pattern on CT scan examination, correlation of the CT scan findings, clinical data, plain chest films, and laboratory results is necessary to define the diagnosis of this uncommon entity.

The spectrum of computerized tomography (CT) findings in central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii in immunocompetent children

Cranial CT scans of eleven immunocompetent children with central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii were retrospectively reviewed. These children had an average age of 8.8 years and positive culture for C. n. var. gattii in cerebrospinal fluid. The most common signs and symptoms were headache, fever, nuchal rigidity, nausea and vomiting. No normal cranial CT was detected in any patient. Hypodense nodules were observed in all patients. The remaining scan abnormalities were as follows: nine had diffuse atrophy, six had hydrocephalus, and five had hydrocephalus coexistent with diffuse atrophy.

Isolation of a Nodulisporium species from a case of cerebral phaeohyphomycosis

A fungal infection of the brain of a 55-year-old male patient is reported. The lesion and involved fungus were located exclusively in the right medial temporo-parietal region. The patient was successfully treated with surgical resection of the lesion and antifungal chemotherapy. Few pathogenic dematiaceous fungi exhibit neurotropism and can cause primary infection in the central nervous system (CNS). The etiological agent is described as a Nodulisporium species. To date Nodulisporium has never been reported as an agent of CNS infection in humans.

Cerebral cryptococcosis: atypical appearances on CT

Cryptococcal infection is common in immunocompromised patients, often presenting with meningitis or meningoencephalitis. We report an unusual presentation of cryptococcal infection in an immunocompetent patient presenting with headache and hemiplegia. CT demonstrated a large ring-enhancing lesion in the parietal region with intralesional calcification.