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Pai V, Sansi R, Kharche R, Bandili SC, Pai B. Rhino-orbito-cerebral Mucormycosis: Pictorial Review. Insights Imaging 2021; 12:167. [PMID: 34767092 PMCID: PMC8587501 DOI: 10.1186/s13244-021-01109-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/10/2021] [Indexed: 01/09/2023] Open
Abstract
Mucormycosis (MCR) is a fulminant, potentially lethal, opportunistic fungal infection. Diabetes, immunocompromised states and elevated serum iron levels are the most important risk factors for contracting MCR infection. Recently, MCR co-infections have been observed in patients with COVID-19 disease owing to a complex interplay of metabolic factors and corticosteroid therapy. Rhino-orbito-cerebral mucormycosis (ROCM) is the most common clinical form of MCR infection and refers to infection of the nasal cavities, paranasal sinuses, neck spaces, orbits and intracranial structures. Sinonasal inoculation is typically the primary site of infection; the necrotising and angioinvasive properties of the fungus facilitate its spread into adjacent structures. In this review, we discuss the pertinent mycology and risk factors of MCR infection. The review also aims to acquaint the reader with the cross-sectional imaging appearances of ROCM and its complications. All the cases discussed in this pictorial essay are microbiologically and/or histopathologically proven cases of ROCM with concomitant COVID-19 infection.
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Affiliation(s)
- Vivek Pai
- Department of Radiology, SevenHills Hospital, Mumbai, India
| | - Rima Sansi
- Department of Radiology, SevenHills Hospital, Mumbai, India
| | - Ritesh Kharche
- Department of Histopathology, SevenHills Hospital, Mumbai, India
| | | | - Bhujang Pai
- Department of Radiology, SevenHills Hospital, Mumbai, India
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Singh H, Dua S, Goel A, Dhar A, Bhadauria V, Garg A, Katyar V, Sharma S, Shukla A. Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience. Surg Neurol Int 2021; 12:538. [PMID: 34754588 PMCID: PMC8571359 DOI: 10.25259/sni_772_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/30/2021] [Indexed: 12/01/2022] Open
Abstract
Background: The gravity of “second wave” of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the “second wave of COVID-19” at a tertiary health care centre in North India. Methods: This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement. Results: All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted. Conclusion: Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.
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Affiliation(s)
- Hershdeep Singh
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Sanjeev Dua
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Amitabh Goel
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Anil Dhar
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Vikram Bhadauria
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Amit Garg
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Vikrant Katyar
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Sumit Sharma
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
| | - Aditi Shukla
- Department of Neurosurgery, Max Hospital, Patparganj, New Delhi, India
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Matsusue E, Inoue C, Tabuchi S, Yoshioka H, Nagao Y, Matsumoto K, Nakamura K, Fujii S. Utility of 3T single-voxel proton MR spectroscopy for differentiating intracranial meningiomas from intracranial enhanced mass lesions. Acta Radiol Open 2021; 10:20584601211009472. [PMID: 34211737 PMCID: PMC8215334 DOI: 10.1177/20584601211009472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 02/03/2023] Open
Abstract
Background Proton magnetic resonance spectroscopy (MRS) provides structural and
metabolic information that is useful for the diagnosis of meningiomas with
atypical radiological appearance. However, the metabolite that should be
prioritized for the diagnosis of meningiomas has not been established. Purpose To evaluate the differences between the metabolic peaks of meningiomas and
other intracranial enhanced mass lesions (non-meningiomas) using MR
spectroscopy in short echo time (TE) spectra and the most useful metabolic
peak for discriminating between the groups. Material and Methods The study involved 9 meningiomas, 22 non-meningiomas, intracranial enhancing
tumors and abscesses, and 15 normal controls. The ranking of the peak at
3.8 ppm, peak at 3.8 ppm/Creatine (Cr), β-γ Glutamine-Glutamate (bgGlx)/Cr,
N-acetyl compounds (NACs)/Cr, choline (Cho)/Cr, lipid and/or lactate
(Lip-Lac) at 1.3 ppm/Cr, and the presence of alanine (Ala) were derived. The
metabolic peaks were compared using the Mann-Whitney U test. ROC analysis
was used to determine the cut-off values for differentiating meningiomas
from non-meningiomas using statistically significant metabolic peaks. Results The ranking of the peak at 3.8 ppm among all the peaks, peak at 3.8 ppm/Cr,
bgGlx/Cr, Lip-Lac/Cr, and the presence of Ala discriminated meningiomas from
non-meningiomas with moderate to high accuracy. The highest accuracy was
96.9% at a threshold value of 3 for the rank of the peak at 3.8 ppm. Conclusion A distinct elevated peak at 3.8 ppm, ranked among the top three highest
peaks, allowed the detection of meningiomas.
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Affiliation(s)
- Eiji Matsusue
- Department of Radiology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Chie Inoue
- Department of Radiology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Sadaharu Tabuchi
- Department of Neurosurgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Hiroki Yoshioka
- Department of Neurosurgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Yuichiro Nagao
- Department of Neurosurgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kensuke Matsumoto
- Department of Radiology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kazuhiko Nakamura
- Department of Radiology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shinya Fujii
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Tottori University, Tottori, Japan
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Ranjan R, Namrata, Singh A, Mody S. MRS Showing a Singlet Peak at 3.8 ppm in Three Patients with CNS Tuberculomas. MAMC JOURNAL OF MEDICAL SCIENCES 2020. [DOI: 10.4103/mamcjms.mamcjms_47_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chikley A, Ben-Ami R, Kontoyiannis DP. Mucormycosis of the Central Nervous System. J Fungi (Basel) 2019; 5:jof5030059. [PMID: 31288475 PMCID: PMC6787740 DOI: 10.3390/jof5030059] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.
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Affiliation(s)
- Amanda Chikley
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, TexasTX 77030, USA.
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Kerezoudis P, Watts CR, Bydon M, Dababneh AS, Deyo CN, Frye JM, Kelley PC, Kemp AM, Palraj BV, Pupillo GT. Diagnosis and Treatment of Isolated Cerebral Mucormycosis: Patient-Level Data Meta-Analysis and Mayo Clinic Experience. World Neurosurg 2018; 123:425-434.e5. [PMID: 30415043 DOI: 10.1016/j.wneu.2018.10.218] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Isolated cerebral mucormycosis is a rare and serious infection associated with intravenous drug abuse. METHODS We performed a comprehensive meta-analysis of cases reported in studies and have included an unreported case from our institution. We searched PubMed/Medline, EMBASE, Scopus, Cochrane Databases, and our institution's electronic medical health records from inception through March 31, 2018. The cases were considered isolated (only affecting the cerebrum, cerebellum, or brainstem) if the absence of other primary sources of infection had been documented. Continuous variables were summarized using the median and interquartile range and categorical variables using frequencies and proportions. The relationships between variables were tested using the Wilcoxon rank sum and Pearson χ2 tests. RESULTS A total of 130 studies (141 patients) met the eligibility requirements and were screened; 68 patients were included. The median age was 28 years (interquartile range, 24-38); 57% were men. Most patients had a history of intravenous drug abuse (82%), and 20% had positive human immunodeficiency virus findings. The lesion location was mostly supratentorial (91%), especially in the basal ganglia (71.2%). The cultures were positive in 38%, with Rhizopus the most common organism (59%). The mortality rate was 65%. The survivors were significantly more likely to have received amphotericin B (92% vs. 43%; P < 0.001) or to have undergone stereotactic aspiration (58% vs. 25%; P < 0.01). CONCLUSIONS Isolated cerebral mucormycosis has a pooled mortality rate of 65%. The presence of lesions in the basal ganglia, rapidly progressive symptoms, and a history of intravenous drug abuse should raise suspicion for the early initiation of amphotericin B and stereotactic aspiration.
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Affiliation(s)
| | - Charles R Watts
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA.
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ala S Dababneh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Infectious Diseases, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Christopher N Deyo
- Department of Hospital Medicine, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Judson M Frye
- Department of Radiology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Parker C Kelley
- Department of Neurosurgery, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Anna M Kemp
- Department of Pathology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Bharath V Palraj
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Infectious Diseases, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Gregory T Pupillo
- Department of Neurology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
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Kochar PS, Lath CO, Klein AP, Ulmer JL. Multimodality imaging in cranial blastomycosis, a great mimicker: Case-based illustration with review of clinical and imaging findings. Indian J Radiol Imaging 2016; 26:120-5. [PMID: 27081235 PMCID: PMC4813061 DOI: 10.4103/0971-3026.178360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We describe the clinical, laboratory, and imaging data of three patients who are proven cases of blastomycosis with cranial involvement. In this review, we discuss the imaging features of cranial blastomycosis with relevant clinical case examples including computed tomography (CT), magnetic resonance imaging (MRI), and advanced MR imaging techniques like magnetic resonance spectroscopy (MRS) and MR perfusion. Literature is reviewed for modern-day diagnosis and treatment of this fatal intracranial infection, if not diagnosed promptly and managed effectively.
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Affiliation(s)
- Puneet S Kochar
- Department of Radiology, Division of Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Chinar O Lath
- Department of Radiology, Division of Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew P Klein
- Department of Radiology, Division of Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John L Ulmer
- Department of Radiology, Division of Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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8
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Morales H, Alfaro D, Martinot C, Fayed N, Gaskill-Shipley M. MR spectroscopy of intracranial tuberculomas: A singlet peak at 3.8 ppm as potential marker to differentiate them from malignant tumors. Neuroradiol J 2015; 28:294-302. [PMID: 26246099 DOI: 10.1177/1971400915592077] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The diagnosis of intracranial tuberculomas is often challenging. Our purpose is to describe the most common metabolic patterns of tuberculomas by MR spectroscopy (MRS) with emphasis on potential specific markers. METHODS Single-voxel MRS short echo time was performed in 13 cases of tuberculomas proven by histology and/or response to anti-mycobacterial therapy. For comparison MRS was also performed in 19 biopsy-proven malignant tumors (13 high-grade gliomas and six metastasis). Presence of metabolic peaks was assessed visually and categorical variables between groups were compared using chi-square. Metabolite ratios were compared using Mann-Whitney test and diagnostic accuracy of the metabolite ratios was compared using receiver-operating characteristic (ROC) curves analysis. RESULTS Spectroscopic peaks representing lipids and glutamate/glutamine (Glx) as well as a peak at ∼3.8 ppm were well defined in 77% (10/13), 77% (10/13) and 69% (nine of 13) of tuberculomas, respectively. Lipid and Glx peaks were also present in most of the malignant lesions, 79% (15/19) and 74% (14/19) respectively. However, a peak at ∼3.8 ppm was present in only 10% (two of 19) of the tumor cases (p < 0.001). Higher Cho/Cr and mI/Cr ratios helped discriminate malignant lesions with an area under the ROC curve of 0.86 (SE: 0.078, p < 0.002, CI: 0.7-1) and 0.8 (SE: 0.1, p < 0.009, CI: 0.6-1), respectively. Threshold values between 1.7-1.9 for Cho/Cr and 0.8-0.9 for mI/Cr provided high specificity (91% for both metabolites) and adequate sensitivity (75% and 80%, respectively) for discrimination of malignant lesions. CONCLUSION A singlet peak at ∼3.8 ppm is present in the majority of tuberculomas and absent in most malignant tumors, potentially a marker to differentiate these lesions. The assignment of the peak is difficult from our analysis; however, guanidinoacetate (Gua) is a possibility. Higher Cho/Cr and mI/Cr ratios should favor malignant lesions over tuberculomas. The presence of lipids and Glx is non-specific.
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Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, Department of Radiology, University of Cincinnati Medical Center, USA
| | | | | | | | - Mary Gaskill-Shipley
- Section of Neuroradiology, Department of Radiology, University of Cincinnati Medical Center, USA
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Radiologic Imaging Techniques for the Diagnosis and Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0227-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Infektionen. NEUROINTENSIV 2015. [PMCID: PMC7175474 DOI: 10.1007/978-3-662-46500-4_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.
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ABO-Sheisha DM, Amin MA, Soliman AY. Role of diffusion weighted imaging and proton magnetic resonance spectroscopy in ring enhancing brain lesions. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Vachhani JA, Lee WC, Desanto JR, Tsung AJ. Magnetic resonance spectroscopy imaging characteristics of cerebral Blastomycosis. Surg Neurol Int 2014; 5:80. [PMID: 24949223 PMCID: PMC4061578 DOI: 10.4103/2152-7806.133306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/14/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Blastomycosis is a dimorphic fungus that is endemic to the midwest and southwestern United States. Involvement of the central nervous system (CNS) is thought to only represent 5-10% of cases of disseminated Blastomycosis. CASE DESCRIPTION A 54-year-old Caucasian female presented to the Neurosurgery service with a 1-day history of progressive right sided hemiparesis. Magnetic resonance imaging (MRI) demonstrated a 2 × 4 cm heterogeneous intracranial mass lesion involving the left motor cortex and extending into the ipsilateral parietal lobe. Single-voxel magnetic resonance spectroscopy (MRS) over the enhancing area demonstrated diminished N-acetyl aspartate (NAA) to creatine ratio (1.10), normal choline to NAA ratio (0.82), normal choline to creatine ratio (0.9), and a diminished myoinositol to creatine ratio (0.39). There appeared to be peaks between 3.6 and 3.8 ppm over the enhancing area that were not present in the contralateral normal brain and thought to represent a "trehalose" peak. Due to worsening symptoms and uncertain preoperative diagnosis, the patient underwent a left fronto-parietal craniotomy for open surgical biopsy with possible resection approximately one month after presentation. Pathological analysis confirmed the diagnosis of Blastomycosis. CONCLUSION We present the second documented case of intracranial Blastomycosis with MRS imaging. There appears to be a characteristic peak between 3.6 and 3.8 ppm that is thought to represent a "trehalose" peak. This peak is rather specific to fungi and can be helpful in differentiating fungal abscesses from pyogenic abscesses and malignant neoplasms.
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Affiliation(s)
- Jay A Vachhani
- Department of Neurosurgery, Illinois Neurological Institute, Peoria, Illinois, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA
| | - William C Lee
- Department of Neurosurgery, Illinois Neurological Institute, Peoria, Illinois, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA
| | - Jeffrey R Desanto
- Department of Radiology, Central Illinois Radiological Associates, University of Illinois, College of Medicine, Peoria, Illinois, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA
| | - Andrew J Tsung
- Department of Neurosurgery, Illinois Neurological Institute, Peoria, Illinois, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA
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Abstract
Infection of the central nervous system can be life-threatening and hence requires early diagnostic support for its optimal management. Routine definitive laboratory diagnostic tests can be time-consuming and delay definitive therapy. Noninvasive imaging modalities have established themselves in the diagnosis of various neurologic diseases. In this article, a pragmatic review of the current role of magnetic resonance spectroscopy in the diagnosis and management of intracranial infections is addressed.
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Affiliation(s)
- Rakesh K Gupta
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India.
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14
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Infektionen. NEUROINTENSIV 2012. [PMCID: PMC7123678 DOI: 10.1007/978-3-642-16911-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.
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15
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Misra BK, Gupta S. Imaging findings in intracranial fungal disease. World Neurosurg 2011; 74:581-2. [PMID: 21492624 DOI: 10.1016/j.wneu.2010.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Basant Kumar Misra
- Department of Neurosurgery, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India.
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Menon S, Bharadwaj R, Chowdhary AS, Kaundinya DV, Palande DA. Utility of in vitro proton magnetic resonance spectroscopy in aetiological characterisation of brain abscesses. Indian J Med Microbiol 2011; 28:348-53. [PMID: 20966567 DOI: 10.4103/0255-0857.71832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Brain abscesses often present an aetiological dilemma. Microscopy is insensitive and culture techniques are time consuming. Hence, a new rapid technique in vitro Proton Magnetic Resonance Spectroscopy (1HMRS) was evaluated for its usefulness in the identification of aetiology of brain abscesses. MATERIALS AND METHODS A total of 39 pus specimens from brain abscesses were subjected to in vitro 1HMRS. These pus specimens were also processed by conventional culture methods. The spectral patterns generated by in vitro 1HMRS were further correlated with culture results. RESULTS Pus specimens which showed the presence of anaerobes on culture revealed the presence of multiplet at 0.9 ppm (100%), lactate-lipid at 1.3 ppm (100%), acetate at 1.92 ppm (100%) and succinate at 2.4 ppm (75%). Pus specimens that revealed the presence of facultative anaerobes on culture showed a pattern B, i.e., the presence of lactate-lipid at 1.3 ppm (100%), acetate at 1.92 ppm (88.88%) along with the multiplet at 0.9 ppm (100%). Pattern C was seen in aerobic infection which showed the presence of lactate-lipid at 1.3 ppm (100%) along with the multiplet at 0.9 ppm. Pus from two tuberculous abscesses showed the complete absence of multiplet at 0.9 ppm. CONCLUSIONS We observed in this study that it was possible to differentiate bacterial and tuberculous brain abscesses using in vitro 1HMRS. Further, it was also possible to distinguish between aerobic and anaerobic brain abscesses on the basis of spectral patterns. In vitro 1HMRS of fungal and actinomycotic brain abscess are also presented for its unusual spectra.
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Affiliation(s)
- S Menon
- Department of Microbiology, Grant Medical College & Sir J.J. Hospital, Mumbai, India.
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Metellus P, Laghmari M, Fuentes S, Eusebio A, Adetchessi T, Ranque S, Bouvier C, Dufour H, Grisoli F. Successful treatment of a giant isolated cerebral mucormycotic (zygomycotic) abscess using endoscopic debridement: case report and therapeutic considerations. ACTA ACUST UNITED AC 2008; 69:510-5; discussion 515. [PMID: 17707491 DOI: 10.1016/j.surneu.2007.02.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 02/13/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cerebral mucormycosis without rhino-orbital or systemic involvement is an extremely rare condition mostly associated with parenteral drug abuse. CASE DESCRIPTION We report the case of a 42-year-old woman who presented with hemiparesis of the left side and altered mental status. Neuroradiologic workup demonstrated an inflammatory lesion involving the right basal ganglia. Proton magnetic resonance spectroscopy demonstrated features consistent with a pyogenic abscess. Computed tomography-guided stereotactic biopsy led to the diagnosis of cerebral mucormycosis. Parenteral AMB-L treatment was conducted, but the patient worsened clinically, presenting with a complete hemiplegia, and cerebral magnetic resonance imaging (MRI) scans demonstrated a voluminous abscess formation. Then, under stereotactic guidance, a surgical endoscopic debridement of the abscess cavity associated with the placement of an Ommaya reservoir was performed. Systemic and intralesional treatment with AmB associated with an adjunctive immune therapy was conducted. At 3-year follow-up, the patient had recovered partially from her left hemiplegia, allowing her to walk without help, and cerebral MRI scans showed complete resorption of the abscess. CONCLUSION Our good results suggest that surgical endoscopic debridement associated with intravenous and intracavitary antifungal therapy might be valuable in treating voluminous deep-seated mucormycotic lesions.
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Koc Z, Koc F, Yerdelen D, Ozdogu H. Rhino-orbital-cerebral mucormycosis with different cerebral involvements: infarct, hemorrhage, and ophthalmoplegia. Int J Neurosci 2008; 117:1677-90. [PMID: 17987470 DOI: 10.1080/00207450601050238] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Rhino-orbital-cerebral mucormycosis is a rare but often fatal opportunistic necrotizing infection of the sinuses, orbit, and brain caused by saprophytic fungi. It usually develops in patients with diabetes or immune system deficiency. In this study, imaging features in 3 patients with rhino-orbital-cerebral mucormycosis who presented with various symptoms and different cerebral involvements are discussed. Headache, blurred vision, fever, painful ophthalmoplegia, and cranial nerve involvement were among the clinical findings. Computed tomography and magnetic resonance imaging are the best imaging methods for assessing the extent of this disease. Relatively typical but nonspecific characteristics are bone destruction, vascular invasion, and central hypointensity in the paranasal sinuses or an intracranial mass that is revealed by T(2)-weighted magnetic resonance imaging. Imaging findings include cavernous sinus involvement, cerebral infarct, and intracerebral hemorrhage. Because of the invasive and fulminant nature of rhino-orbital-cerebral mucormycosis, successful treatment seems to be based on early diagnosis and on the management of underlying immunologic problems.
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Affiliation(s)
- Zafer Koc
- Department of Radiology, Başkent University Medical School, Adana, Turkey.
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19
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Carpenter M, Polk C, Castellani R, Mochoruk K, Sanche S, Stern B, Donnenberg MS. Encephalitis of the basal ganglia in an injection drug user. Clin Infect Dis 2007; 45:1479, 1522-4. [PMID: 17990237 DOI: 10.1086/522995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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20
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Morais LT, Zanardi VDA, Faria AV. Magnetic resonance spectroscopy in the diagnosis and etiological definition of brain bacterial abscesses. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:1144-8. [DOI: 10.1590/s0004-282x2007000700010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 09/15/2007] [Indexed: 11/21/2022]
Abstract
We report two patients with bacterial brain abscesses whose etiological diagnosis was correctly proposed by association of diffusion weighted images (DWI) and magnetic resonance spectroscopy (MRS) with conventional MRI. Both patients presented ring enhancing lesions with evidences of restricted diffusion. On MRS, the abscess caused by aerobic bacteria presented lactate and aminoacids peaks and the abscess caused by anaerobic facultative bacteria showed also acetate and succinate peaks. These results are in agreement with an unique previous study that related MRS pattern with bacterial etiology. Conventional MRI, associated with DWI and MRS is effective in diagnosing bacterial abscess and promising in exploring its etiology.
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21
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Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, Husain M, Singh S, Behari S, Gupta RK. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007; 28:1332-8. [PMID: 17698537 PMCID: PMC7977670 DOI: 10.3174/ajnr.a0548] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE It is difficult to differentiate the cause of brain abscesses with the use of CT and MR imaging. We did a comparative evaluation of pyogenic, tubercular, and fungal brain abscesses by using conventional, diffusion-weighted imaging (DWI), and proton MR spectroscopy (PMRS) with an aim to define the unique features that may differentiate among the pyogenic, tubercular, and fungal brain abscesses. MATERIALS AND METHODS We performed a retrospective analysis on 110 patients with surgically proved brain abscesses. Imaging studies included T2, T1, postcontrast T1, DWI, and PMRS. Apparent diffusion coefficient (ADC) of the wall and cavity of the abscesses were quantified. The morphologic, physiologic, and metabolite features of pyogenic (n=91), tubercular (n=11), and fungal (n=8) abscesses were compared. RESULTS The pyogenic abscesses had smooth (55/91) and lobulated (36/91) walls, whereas the tubercular abscesses had smooth (4/11), lobulated (6/11), or crenated walls (1/11) with no intracavitary projections. The fungal abscesses showed irregular walls (lobulated 4/8, crenated 4/8) with intracavitary projections (8/8). The wall as well as the cavity showed low ADC in the pyogenic and tubercular abscesses. In the fungal abscesses, the wall and projections showed low ADC (8/8); however, the cavity itself showed high ADC (8/8). PMRS showed cytosolic amino acids (89/91), acetate (25/91), and succinate (18/91) in the pyogenic abscesses, whereas lipid/lactate (11/11) was seen in the tubercular abscesses. The fungal abscesses showed lipid (4/8), lactate (7/8), amino acids (4/8), and multiple peaks between 3.6 and 3.8 ppm assigned to trehalose (5/8). CONCLUSION Based on the morphologic, ADC, and metabolite information, it may be possible to differentiate among the pyogenic, tubercular, and fungal brain abscesses.
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Affiliation(s)
- G Luthra
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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22
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Cuellar H, Riascos R, Palacios E, Rojas R, Molina P. Imaging of isolated cerebral mucormycosis. A report of three cases. Neuroradiol J 2007; 20:525-30. [PMID: 24299941 DOI: 10.1177/197140090702000509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 07/29/2007] [Indexed: 11/16/2022] Open
Abstract
Mucormycosis is a rare infection in immunosupressed patients caused by fungi from the family Mucoraceae. Three types of disease spread have been described: rhinocerebral, systemic and isolated. Isolated spread is the most uncommon form, usually resulting in death. It has been described in diabetics, immunosupressed patients and intravenous drug abusers. Neuroimaging can aid the diagnosis of this entity, but biopsy remains the only reliable method. Imaging findings of Mucormycosis include abscesses and hemorrhagic or ischemic infarcts, usually in the basal ganglia and frontal lobes. Single or multiple lesions have been described as well as meningoencephalitis. Understanding these findings can help to detect the infection in an early stage. We describe three cases of isolated cerebral mucormycosis; all of them were intravenous drug abusers with one patient also being HIV positive.
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Affiliation(s)
- H Cuellar
- Department of Endovascular Therapy , Interventional Neuroradiology Fellow, Clinica Nuestra Señora del Rosario; Madrid, España -
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23
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Horger M, Hebart H, Schimmel H, Vogel M, Brodoefel H, Oechsle K, Hahn U, Mittelbronn M, Bethge W, Claussen CD. Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation. Br J Radiol 2006; 79:e88-95. [PMID: 16940368 DOI: 10.1259/bjr/16038097] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Disseminated mucormycosis is a rare, mostly fatal infectious complication in immunocompromised haematological patients. The purpose of our study was to describe the multiorgan manifestations of disseminated mucormycosis documented at CT and MRI in four patients and correlate these with the pathological findings and patient outcome. Irrespective of the site of infection, infarction or haemorrhage are the constant features of invasive mycosis. Identification of one or both of these two major imaging findings in immunocompromised patients should be regarded as an indicator of possible infection by angiotropic fungi, including the genre Mucorales.
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Affiliation(s)
- M Horger
- Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str.3, 72076 Tübingen, Germany
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Kingsley PB, Shah TC, Woldenberg R. Identification of diffuse and focal brain lesions by clinical magnetic resonance spectroscopy. NMR IN BIOMEDICINE 2006; 19:435-62. [PMID: 16763970 DOI: 10.1002/nbm.1039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The purpose of this paper is to facilitate the comparison of magnetic resonance (MR) spectra acquired from unknown brain lesions with published spectra in order to help identify unknown lesions in clinical settings. The paper includes lists of references for published MR spectra of various brain diseases, including pyogenic abscesses, encephalitis (herpes simplex, Rasmussen's and subacute sclerosing panencephalitis), neurocysticercosis, tuberculoma, cysts (arachnoid, epidermoid and hydatid), acute disseminated encephalomyelitis (ADEM), adrenoleukodystrophy (ALD), Alexander disease, Canavan's disease, Krabbe disease (globoid cell leukodystrophy), Leigh's disease, megalencephalic leukoencephalopathy with cysts, metachromatic leukodystrophy (MLD), Pelizaeus-Merzbacher disease, Zellweger syndrome, HIV-associated lesions [cryptococcus, lymphoma, toxoplasmosis and progressive multifocal leukoencephalopathy (PML)], hydrocephalus and tuberous sclerosis. Each list includes information on the echo time(s) (TE) of the published spectra, whether a control spectrum is shown, whether the corresponding image and voxel position are shown and the patient ages if known. The references are listed in the approximate order of usefulness, based on spectral quality, number of spectra, range of echo times and whether the voxel positions are shown. Spectra of Zellweger syndrome, cryptococcal infection, toxoplasmosis and lymphoma are included, along with a spectrum showing propanediol (propylene glycol).
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Affiliation(s)
- Peter B Kingsley
- Department of Radiology, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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Brockmann K, Bjornstad A, Dechent P, Korenke CG, Smeitink J, Trijbels JMF, Athanassopoulos S, Villagran R, Skjeldal OH, Wilichowski E, Frahm J, Hanefeld F. Succinate in dystrophic white matter: a proton magnetic resonance spectroscopy finding characteristic for complex II deficiency. Ann Neurol 2002; 52:38-46. [PMID: 12112045 DOI: 10.1002/ana.10232] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A deficiency of succinate dehydrogenase is a rare cause of mitochondrial encephalomyopathy. Three patients, 2 sisters and 1 boy from an unrelated family, presented with symptoms and magnetic resonance imaging signs of leukoencephalopathy. Localized proton magnetic resonance spectroscopy indicated a prominent singlet at 2.40ppm in cerebral and cerebellar white matter not present in gray matter or basal ganglia. The signal was also elevated in cerebrospinal fluid and could be identified as originating from the two equivalent methylene groups of succinate. Subsequently, an isolated deficiency of complex II (succinate:ubiquinone oxidoreductase) was demonstrated in 2 patients in muscle and fibroblasts. One of the sisters died at the age of 18 months. Postmortem examination showed the neuropathological characteristics of Leigh syndrome. Her younger sister, now 12 months old, is also severely affected; the boy, now 6 years old, follows a milder, fluctuating clinical course. Magnetic resonance spectroscopy provides a characteristic pattern in succinate dehydrogenase deficiency.
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Affiliation(s)
- Knut Brockmann
- Department of Pediatrics and Neuropediatrics, Children's Hospital, University of Göttingen, Göttingen, Germany.
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