Central nervous system Aspergillus infection after epidural analgesia: diagnosis, therapeutic challenges, and literature review

Cervical Intradural Fungal Infection Masquerading as a Meningioma in an Immunocompetent Patient: A Case Report and Systematic Review

BACKGROUND

Intradural spinal fungal infection is a rare phenomenon that can carry a significant increase in morbidity and mortality. This systematic review and case report provides a presentation of a 75-year-old male patient with an intradural cervical mass that was diagnosed as a fungal infection intraoperatively. We analyze and report on intradural spinal fungal infections in immunocompetent patients.

METHODS

We performed a systematic literature review following the PRISMA protocol for studies of intradural fungal infections published in the past 25 years. Original articles with a description of treatment outcomes of such patients were included.

RESULTS

A total of 8 studies were included in this review with the addition of the present case. There were 5 male and 4 female patients with an average age of 45.6 yeaers (range 24-75 years). Aspergillus and Candida species being the most isolated fungal organism. The origin of the lesions was identified and iatrogenic in 4 cases. Most patients underwent decompressive laminectomy with biopsy, abscess drainage, or resection of the identified lesion. There were 2 instances of cervical lesions, but most of the lesions were in the thoracic and lumbar spine. Half of the cases reported symptoms improvement, but 2 patients died from the infection or complications from the infections.

CONCLUSIONS

Intradural fungal infections are rare, with only 10 total cases reported in the past 25 years. Nonetheless, they can be associated with significant mortality and morbidity. Thus, the timeline from presentation to intervention should be evaluated and determined carefully.

Isavuconazole Treatment of Spinal Cord Invasive Aspergillosis Guided by Cerebrospinal Fluid (1,3)-β-d-Glucan Levels in a Patient with Low Interferon-Gamma and Ulcerative Colitis

This case highlights the use of (1,3)-beta-d glucan to direct treatment of a cervical spinal cord Aspergillus fumigatus infection in a 22-year-old woman immunocompromised due to steroid and anti-TNF therapy in the context of ulcerative colitis and interferon gamma deficiency. A 4-year treatment course requiring neurosurgical intervention on four occasions and prolonged antifungal therapy, including isavuconazole, resulted in clinical cure with a corresponding decrease in CSF beta-d-glucan to <30 pg/mL. Serum and CSF galactomannan levels were not elevated at any point during the clinical course.

Clinical manifestations, diagnosis, and treatment outcome of CNS aspergillosis: A systematic review of 235 cases

Aspergillus is a ubiquitous ascomycete that can cause a variety of clinical presentations depending on immune status. Central nervous system aspergillosis is a fatal disease with non-specific clinical features. The aim of this systematic review was to evaluate the epidemiology, clinical features, diagnosis and therapeutic interventions in CNS aspergillosis patients. We also aimed to examine the possible predictors of mortality in neuroaspergillosis. Literature search was performed in Medline, PubMed, and Google scholar and all patients≥18 years with proven CNS aspergillosis were included. A total of 175 articles (235 patients) were included in the final analysis. Their mean age was 51 years and the majority were male (57.4%). Overall case-fatality was 45.1%. Aspergillus fumigatus was the most common species (70.8%) followed by A. flavus (18.6%). Corticosteroids (22.6%), malignancy (19.1%) and diabetes mellitus (14%) were the most common risk factors. Neuroimaging findings included cerebral abscess (70.2%), meningitis (14%), infarction (13.2%) and mycotic aneurysm (8.9%). Disseminated disease (29.2% vs 17.8%, p 0.03), CSF hypoglycorrhachia (48.1% vs 22.2%, P: 0.001) and heightened CSF galactomannan (3.62 vs 2.0ng/ml, p 0.05), were the factors associated with poor outcome in neuroaspergillosis. Persons infected with Aspergillus flavus (13.1% vs 3.1%, P: 0.01), and having been treated with Voriconazole (51.9% vs 29.2%, P: 0.004) were more likely to survive. Our review will provide insight into the different spectrums of CNS aspergillosis. Notwithstanding the promising role of Voriconazole, future work is required to ascertain the role of combination antifungal therapy.

Progress in the treatment of fungal infections of the central nervous system

The incidence of fungal infections of the central nervous system (CNS) has gradually increased in recent years. Intracranial fungal infection can be classified as diffuse and focal infections. The clinical manifestations of these infections include fever and cranial pressure caused by meningitis or meningoencephalitis, as well as focal neurological defects caused by lesions in the intracranial space. Diagnosing fungal infections of the CNS requires comprehensive analysis of the patient’s medical history, epidemiology, underlying disease, clinical manifestation, imaging manifestations, and results from various laboratory tests. The identification of fungal bodies or structures in brain tissue or cerebrospinal fluid specimens is the golden standard of diagnosis. The principles for the treatment of fungal infections of the CNS are the effective control of pathogenic risk factors, use of effective antifungal drugs, and the active implementation of surgical intervention for fungal abscesses and granulomas. In the meantime, new diagnoses and treatments should be actively explored to improve the prognosis of patients.

Intracranial Aspergillosis in an Immunocompetent Young Woman

Intracranial aspergillosis (ICA) is very rare in the immunocompetent individuals, usually misdiagnosed as a tumor or an abscess. A high index of clinical suspicion is required in patients who present with focal neurological deficits, headache, or seizures. We report the case of a 25-year-old immunocompetent female, who presented with a 15-month history of headache, seizures, left-sided proptosis and ophthalmoplegia, and right hemiparesis. Recovery from the symptoms and decrease in the lesion size seen on the radiological assessment were achieved through two decompressive craniotomies followed by prolonged combined systemic antifungal therapies. Although the initial neuroimaging suggested a mitotic pathology, the surgical sample confirmed ICA. Now the patient is on single antifungal therapy (Tab. voriconazole, 200 mg twice daily) and doing her daily activities, but with a reduced intelligent quotient. We report a challenging case of ICA where multiple courses of combined antifungal therapies and repeat surgeries paved the way for a good prognosis.

Intracranial aspergillus fumigatus infection complicated with cavernous hemangioma: case report and literature review

The aim of this study was to report a rare case of Aspergillus fumigatus infection complicated with cavernous hemangioma in the central nervous system of a patient with normal immune function and to investigate its causes. A 60-year-old male patient was admitted three years ago due to meningioma-induced convulsions. In addition to meningioma, magnetic resonance imaging (MRI) results also suggested the presence of cystic and solid lesions in the left temporal lobe, which was considered to be a brain abscess due to the infection. After antibiotic treatment, the patient underwent meningioma resection, after which no more convulsions occurred. It was recommended that the patient receive treatment on the abscess in the left temporal lobe, but the patient did not consent. He was discharged with follow-up. Recently, the patient returned for treatment due to intermittent headaches with weakness in the right lower extremity for 10 days. MRI results revealed that the lesion in the left temporal lobe had expanded and was associated with abnormality in the midline. Surgical lumpectomy was performed, and the postoperative pathological examination confirmed the brain abscess to be an Aspergillus fumigatus infection complicated with cavernous hemangioma, which indirectly confirmed that the lesion in the temporal lobe three years ago was from the Aspergillus fumigatus infection. On the 7th postoperative day, the patient died due to severe pneumonia. Because the intracranial Aspergillus fumigatus infection in the patient had lasted for three years, with no cavernous hemangioma present at the first assessment but with a lesion evident three years later, the hemangioma is considered to be related to the Aspergillus fumigatus infection.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

Treatment of Aspergillus terreus infections: a clinical problem not yet resolved

Despite the use of recommended therapies, invasive infections by Aspergillus terreus show a poor response. For years, investigative studies on the failure of therapy of fungal infections have focused on in vitro susceptibility data. However, it is well known that low minimum inhibitory concentrations (MICs) are not always predictive of response to therapy despite a correct dosage schedule. Many experimental and clinical studies have tried to establish a relationship between MICs and outcome in serious fungal infections but have come to contradictory and even surprising conclusions. The success or failure of treatment is determined by many factors, including the in vitro susceptibility of the causative fungal isolate, the pharmacokinetics/pharmacodynamics of the drug used for treatment, pharmacokinetic variability in the population, and the underlying disease that patients suffer. To try to understand this poor response to treatment, available data on the in vitro susceptibility of A. terreus, the experimental and clinical response to amphotericin B, triazoles and echinocandins, and the pharmacokinetics/pharmacodynamics of these antifungals have been reviewed. Of special interest are the fungistatic activites of these drugs against A. terreus and the high interpatient variability of serum drug levels observed in therapy based on triazoles, which make monitoring of infected patients necessary.

Aspergillus meningitis: a rare clinical manifestation of central nervous system aspergillosis. Case report and review of 92 cases

OBJECTIVES

To describe the pathogenesis, clinical presentation, cerebrospinal fluid findings and outcome of Aspergillus meningitis, meningoencephalitis and arachnoiditis.

METHODS

A case of Aspergillus meningitis is described. A comprehensive review of the English-language literature was conducted to identify all reported cases of Aspergillus meningitis described between January 1973 and December 2011.

RESULTS

Ninety-three cases (including the one described herein) of Aspergillus meningitis were identified. Fifty-two (55.9%) were in individuals without any predisposing factor or known causes of immunosuppression. Acute and chronic meningitis was diagnosed in 65.6% of patients and meningoencephalitis in 24.7% of them with the remaining presenting with spinal arachnoiditis and ventriculitis. Cerebrospinal fluid cultures for Aspergillus spp. were positive in about 31% of cases and the galactomannan antigen test in 87%. Diagnosis during life was achieved in 52 patients (55.9%) with a case fatality rate of 50%. The overall case fatality rate was 72.1%.

CONCLUSIONS

Aspergillus meningitis may occur in both immunocompetent and immunocompromised patients and run an acute or chronic course. The findings of this systematic review extend the information on this life-threatening infection and could assist physicians in achieving an improved outcome.

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.

Aspergillosis in the 'nonimmunocompromised' host

Invasive aspergillosis has been classically associated with certain risk factors: cytotoxic chemotherapy, prolonged neutropenia, corticosteroids, transplantation, AIDS. However, the literature is growing that this mycosis, particularly pulmonary aspergillosis, can be seen in patients lacking these factors. Many of the latter patients are in the intensive care unit. Other associated conditions include influenza, nonfungal pneumonia, chronic obstructive lung disease, immaturity, sepsis, liver failure, alcoholism, chronic granulomatous disease and surgery. Certain focal sites, such as sinusitis or cerebral aspergillosis, have additional risk factors. This emphasizes the potential importance of a positive culture for Aspergillus in the critically ill, the need for awareness about possible aspergillosis in patients lacking the classical risk factors, and readiness to proceed with appropriate diagnostic maneuvers.

Identification of lethal Aspergillus at early growth stages based on matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Delayed and incorrect diagnoses are potential risk factors leading to high mortality of invasive aspergillosis (IA). Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry was used to acquire a wide mass spectral range and characterize the early process of asexual sporulation of lethal IA pathogens recovered on agar plates. Proteins were extracted using trifluoroacetic acid and soft ionized using an ultraviolet laser with the assistance of ferulic acid. At the second stage of sporulation with various differentiated structures, there are more specific peaks that can be used to discriminate different Aspergillus species than at the first stage, which features vegetative hyphae. Certain specific peaks are found in different strains of the same species, Aspergillus fumigatus. In addition, the relative standard deviations of the m/z ratios are much smaller than those of the relative intensities in these peaks. Therefore, common lethal Aspergillus species can be identified after short-term cultivation by matching species-specific m/z values.

[Primitive aspergillosis of the posterior cerebral fossa in immunocompetent patient]

Cerebral aspergillosis arises in the great majority of cases during an invasive aspergillosis with hematogene scattering from the lung hurts. The cerebral, not rare location is one of the worse criteria forecast during the invasive aspergillosis. We report the case of patient who was hospitalized in the neurosurgery department for syndrome of increased intracranial pressure, hemiparesis and cerebellar syndrome in febrile context. The radiological exploration objectified a collection of the posterior fossa. A stereotactic biopsy was performed. It collected fragments biopsy and pus. The pathological and microbiological analysis allowed the identification of Aspergillus fumigatus. The originality of this observation comes from the rare location in the posterior fossa of aspergillosis and because the patient is immunocompetent and no primary location is found. The patient presents however a viral hepatitis B of fortuitous discovery. He is put under treatment by amphotericin B. The evolution is marked by meningitis comment-diversion. Antibiotics are prescribed, and then the patient is operated for total ablation of the tumor. He dies following an osmolar coma associated with thrombopenia and a secondary renal insufficiency due to his treatment by the amphotericin B.