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Ganesan V, Hallur V, Velvizhi S, Rajendran T. Cerebral phaeohyphomycosis due to Cladophialophora bantiana: case report and systematic review of cases. Infection 2024; 52:313-321. [PMID: 37979132 DOI: 10.1007/s15010-023-02126-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Cladophialophora bantiana is a wonted melanized fungus causing brain abscess. In past many cases were reported from Asia, particularly from India. Of late, there is a rise in cases in places besides Asia and hence a review of the cases is warranted. METHODS We present a case of fatal cerebral phaeohyphomycosis caused by C. bantiana and conduct a systematic review of culture confirmed brain abscess due to C. bantiana reported between 2015 and 2022. RESULTS Of the 39 cases found, majority (68%) were immunocompromised. The various clinical presentations were headache (53%), hemiparesis (34%), visual disturbance (25%), altered sensorium (18%), aphasia/dysarthria (12%) and seizures (9%). Isolated lesion was observed in 18 (60%) patients. In the sequence of occurrence, the lesions were in frontal (30%), temporal (27%) and parietal (20%) region. There were five cases with coinfections such as concurrent detection of Nocardia pneumonia in two cases, toxoplasma DNA in brain abscess, coexisting pulmonary Cryptococcus neoformans infection and coexisting Candida in a case of brain abscess in one case each. Surgical intervention was performed in 84% cases. Antifungal therapy included voriconazole (80%), liposomal amphotericin B (76%), 5-fluorocytosine (30%), posaconazole (10%), and amphotericin B deoxycholate (6%). The overall mortality was 50% with lower mortality (42%) in regions outside Asia compared to Asia (63.6%) though not statistically significant. CONCLUSIONS C. bantiana brain abscess is an emerging infection worldwide. Next generation sequencing is an upcoming promising diagnostic test. Early complete excision of the lesion with effective antifungals may improve the outcome.
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Affiliation(s)
- Vithiya Ganesan
- Velammal Medical College Hospital and Research Institute, Madurai, India.
| | - Vinaykumar Hallur
- All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
| | - S Velvizhi
- Velammal Medical College Hospital and Research Institute, Madurai, India
| | - T Rajendran
- Velammal Medical College Hospital and Research Institute, Madurai, India
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Ghanouni A, Avila SA, de la Garza AG, Sharfi D, Singiser H, Stampfer SD, Lyon GM, Babiker A. Cladophialophora bantiana orbital cellulitis after penetrating injury. Orbit 2023:1-6. [PMID: 36847499 DOI: 10.1080/01676830.2023.2181976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/12/2023] [Indexed: 03/01/2023]
Abstract
A 75-year-old immunocompetent male presented with a right orbital cellulitis after a foreign body penetrating injury. He was taken for orbitotomy with foreign body removal and started on broad-spectrum antibiotics. Intra-operative cultures were positive for Cladophialophora bantiana, a mold known for causing brain abscesses with no prior reports of orbital invasion in the literature. Following culture results, the patient was managed with voriconazole and required multiple orbitotomies and washouts for infection control.
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Affiliation(s)
- Arian Ghanouni
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sarah A Avila
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Adam G de la Garza
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Duaa Sharfi
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Heather Singiser
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Samuel D Stampfer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George Marshall Lyon
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Kilbourn KJ, Green J, Zacharewski N, Aferzon J, Lawlor M, Jaffa M. Intracranial fungal Cladophialophora bantiana infection in a nonimmunocompromised patient: A case report and review of the literature. Surg Neurol Int 2022; 13:165. [PMID: 35509580 PMCID: PMC9062923 DOI: 10.25259/sni_116_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/01/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Cladophialophora bantiana is a dematiaceous fungus that rarely infects the central nervous system (CNS). It is associated with a mortality rate of over 70% despite treatment.
Case Description:
An 81-year-old female with a remote history of renal cell carcinoma presented with progressive headache and an expressive aphasia for 3 days. Computed tomography imaging revealed a left frontotemporal mass with surrounding vasogenic edema. A left frontotemporal craniotomy was performed and cultures revealed C. bantiana. The initial management with IV voriconazole was unsuccessful and the patient had a recurrence of the cranial infection and developed pulmonary abscesses. Following the addition of oral flucytosine, the patient showed a significant improvement with a complete radiographic resolution of both the cranial and pulmonary lesions.
Conclusion:
C. bantiana involving the CNS is a rare and often fatal disease. Surgical management along with standard antifungal treatment may not provide definitive therapy. The addition of flucytosine to IV voriconazole resulted in a positive outcome for this patient who is alive, living independently 1 year from the original diagnosis. In this rare fungal infection, standard antifungal treatment may not provide adequate coverage and the utilization of additional therapy may be required.
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Affiliation(s)
- Kent J. Kilbourn
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, United States,
| | - Jaquise Green
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, United States,
| | - Nicholas Zacharewski
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, United States,
| | - Joseph Aferzon
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, United States,
| | - Michael Lawlor
- Department of Infectious Disease, Hartford Hospital, Hartford, Connecticut, United States,
| | - Matthew Jaffa
- Department of Neurointensive Care, Hartford Hospital, Hartford, Connecticut, United States
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Central Nervous System Fungal Infections in Paediatric Patients. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-021-00427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mody P, Wada P, Bloch KC, Lionakis MS, White KD, Maris AS, Snyder T, Steinhauer J, Humphries R. Gram stain to the rescue: a case report of cerebral phaeohyphomycosis by Cladophialophora bantiana in an immunocompetent 24-year-old. BMC Infect Dis 2022; 22:13. [PMID: 34983414 PMCID: PMC8725554 DOI: 10.1186/s12879-021-07008-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Fungal brain abscesses in immunocompetent patients are exceedingly rare. Cladophialophora bantiana is the most common cause of cerebral phaeohyphomycosis, a dematiaceous mold. Radiological presentation can mimic other disease states, with diagnosis through surgical aspiration and growth of melanized fungi in culture. Exposure is often unknown, with delayed presentation and diagnosis. CASE PRESENTATION We present a case of cerebral phaeohyphomycosis in a 24-year-old with no underlying conditions or risk factors for disease. He developed upper respiratory symptoms, fevers, and headaches over the course of 2 months. On admission, he underwent brain MRI which demonstrated three parietotemporal rim-enhancing lesions. Stereotactic aspiration revealed a dematiaceous mold on staining and the patient was treated with liposomal amphotericin B, 5-flucytosine, and posaconazole prior to culture confirmation. He ultimately required surgical excision of the brain abscesses and prolonged course of antifungal therapy, with clinical improvement. CONCLUSIONS Culture remains the gold standard for diagnosis of infection. Distinct microbiologic findings can aid in identification and guide antimicrobial therapy. While little guidance exists on treatment, patients have had favorable outcomes with surgery and combination antifungal therapy. In improving awareness, clinicians may accurately diagnose disease and initiate appropriate therapy in a more timely manner.
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Affiliation(s)
- Perceus Mody
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA.
| | - Paul Wada
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen C Bloch
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Annapolis, MD, USA.,Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Annapolis, MD, USA
| | - Katie D White
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander S Maris
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Tonya Snyder
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Jennifer Steinhauer
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
| | - Romney Humphries
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, 1301 Medical Center Dr., TVC 4524, Nashville, TN, 37232, USA
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Velasco J, Revankar S. CNS Infections Caused by Brown-Black Fungi. J Fungi (Basel) 2019; 5:jof5030060. [PMID: 31295828 PMCID: PMC6787688 DOI: 10.3390/jof5030060] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022] Open
Abstract
Central nervous system (CNS) infections caused by brown-black or dematiaceous fungi are distinctly rare and represent a small proportion of infections termed phaeohyphomycoses. However, these are becoming more commonly reported. Though many fungi have been implicated in disease, most cases are caused by only a few species, Cladophialophora bantiana being the most common. Most of the fungi described are molds, and often cause infection in immunocompetent individuals, in contrast to infection with other more common molds such as Aspergillus, which is usually seen in highly immunocompromised patients. Diagnosis is challenging, as there are no specific tests for this group of fungi. In addition, these infections are often refractory to standard drug therapies, requiring an aggressive combined surgical and medical approach to improve outcomes, yet mortality remains high. There are no standardized treatments due to a lack of randomized clinical trials, though guidelines have been published based on available data and expert opinion.
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Affiliation(s)
- Jon Velasco
- Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA
| | - Sanjay Revankar
- Division of Infectious Diseases, Department of Medicine, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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Gniadek TJ, Cappel MA, Wengenack NL, Libertin CR. Eumycetoma caused by Cladophialophora bantiana in the United States. Access Microbiol 2019; 1:e000030. [PMID: 32974540 PMCID: PMC7481735 DOI: 10.1099/acmi.0.000030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/14/2019] [Indexed: 11/25/2022] Open
Abstract
A female presented in the sixth decade of life with a history of undifferentiated small cell carcinoma of the right breast in clinical remission, status-post chemotherapy and resection 6 years previously, presented with a chronic anterior knee skin nodule that grew in size over the prior 5–6 weeks. She had no history of opportunistic infections or recent immunosuppression. As it grew, the nodule became tender to touch. Examination revealed a 4–6 mm superficial purple-red nodule. Also, a similar lesion was present on the dorsum of her left foot for the past year, which also recently grew and became tender. The patient did report frequently kneeling on soil when gardening in Florida. She reported no other symptoms. Due to a concern for cutaneous metastasis of the patient’s previously diagnosed small cell carcinoma of the breast, the anterior knee lesion was biopsied. Histology revealed histocyte-rich inflammation with foci of acute inflammation as well as pigmented fungal forms. Subsequent fungal culture of excised tissue grew Cladophialophora bantiana, identified by ribosomal gene DNA sequencing.
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Affiliation(s)
- Thomas J Gniadek
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.,Present address: NortShore University Health System, Evanston, IL 60201, USA
| | - Mark A Cappel
- Department of Dermatology, Mayo Clinic, Jacksonville, FL 32224, USA.,Present address: Gult Coast Dermatopathology Laboratory, 6001 Memorial Highway, Tampa, FL 33615, USA
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Claudia R Libertin
- Division of Infectious Disease, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
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Abstract
BACKGROUND Fungal infections of the central nervous system (FIs-CNS) have become significantly more common over the past 2 decades. Invasion of the CNS largely depends on the immune status of the host and the virulence of the fungal strain. Infections with fungi cause a significant morbidity in immunocompromised hosts, and the involvement of the CNS may lead to fatal consequences. METHODS One hundred and thirty-five articles on fungal neuroinfection in PubMed, Google Scholar, and Cochrane databases were selected for review using the following search words: "fungi and CNS mycoses", CNS fungal infections", "fungal brain infections", " fungal cerebritis", fungal meningitis", "diagnostics of fungal infections", and "treatment of CNS fungal infections". All were published in English with the majority in the period 2000-2018. This review focuses on the current knowledge of the epidemiology, clinical presentations, diagnosis, and treatment of selected FIs-CNS. RESULTS The FIs-CNS can have various clinical presentations, mainly meningitis, encephalitis, hydrocephalus, cerebral abscesses, and stroke syndromes. The etiologic factors of neuroinfections are yeasts (Cryptococcus neoformans, Candida spp., Trichosporon spp.), moniliaceous moulds (Aspergillus spp., Fusarium spp.), Mucoromycetes (Mucor spp., Rhizopus spp.), dimorphic fungi (Blastomyces dermatitidis, Coccidioides spp., Histoplasma capsulatum), and dematiaceous fungi (Cladophialophora bantiana, Exophiala dermatitidis). Their common route of transmission is inhalation or inoculation from trauma or surgery, with subsequent hematogenous or contiguous spread. As the manifestations of FIs-CNS are often non-specific, their diagnosis is very difficult. A fast identification of the etiological factor of neuroinfection and the application of appropriate therapy are crucial in preventing an often fatal outcome. The choice of effective drug depends on its extent of CNS penetration and spectrum of activity. Pharmaceutical formulations of amphotericin B (AmB) (among others, deoxycholate-AmBd and liposomal L-AmB) have relatively limited distribution in the cerebrospinal fluid (CSF); however, their detectable therapeutic concentrations in the CNS makes them recommended drugs for the treatment of cryptococcal meningoencephalitis (AmBd with flucytosine) and CNS candidiasis (L-AmB) and mucormycosis (L-AmB). Voriconazole, a moderately lipophilic molecule with good CNS penetration, is recommended in the first-line therapy of CNS aspergillosis. Other triazoles, such as posaconazole and itraconazole, with negligible concentrations in the CSF are not considered effective drugs for therapy of CNS fungal neuroinfections. In contrast, clinical data have shown that a novel triazole, isavuconazole, achieved considerable efficacy for the treatment of some fungal neuroinfections. Echinocandins with relatively low or undetectable concentrations in the CSF do not play meaningful role in the treatment of FIs-CNS. CONCLUSION Although the number of fungal species causing CNS mycosis is increasing, only some possess well-defined treatment standards (e.g., cryptococcal meningitis and CNS aspergillosis). The early diagnosis of fungal infection, accompanied by identification of the etiological factor, is needed to allow the selection of effective therapy in patients with FIs-CNS and limit their high mortality.
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Affiliation(s)
- Katarzyna Góralska
- Department of Biomedicine and Genetics, Medical University of Lodz, Pomorska 251, 92-213, Lodz, Poland.
| | - Joanna Blaszkowska
- Department of Diagnostics and Treatment of Parasitic Diseases and Mycoses, Medical University of Lodz, Pomorska 251, 92-213, Lodz, Poland
| | - Magdalena Dzikowiec
- Department of Diagnostics and Treatment of Parasitic Diseases and Mycoses, Medical University of Lodz, Pomorska 251, 92-213, Lodz, Poland
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