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

Cerebral cryptococcoma successfully treated by isavuconazole in an immunocompetent patient: A case report

Cryptococcosis has been recognized as an increasing cause of severe systemic mycosis in immunocompetent patients in the last few years. Cerebral cryptococcomas are a more uncommon manifestation of cryptococcal meningitis, which are not usually included in the differential of brain masses. We report a case of a young, immunocompetent woman that rapidly developed severe neurological deficits. She was ultimately diagnosed with cerebral cryptococcoma caused by both Cryptococcus neoformans and Cryptococcus gattii, and was treated with amphotericin B and isavuconazole. After several complications during hospitalization, including hydrocephalus and cerebellitis, she was discharged home on isavuconazole. On follow-up, she only complained of anosmia. We review the clinical and radiological findings of similar cases. It is the first time that this form of cryptococcal meningitis is favorably treated with isavuconazole and is caused by 2 species of Cryptococcus. We emphasize that cerebral cryptococcomas should be suspected in immunocompetent patients that present with brain masses.

Mechanism of extracellular space changes in cryptococcal brain granuloma revealed by MRI tracer

Purpose

This study aimed to investigate the changes in extracellular space (ECS) in cryptococcal brain granuloma and its pathological mechanism.

Materials and methods

The animal model of cryptococcal brain granuloma was established by injecting 1 × 10⁶ CFU/ml of Cryptococcus neoformans type A suspension into the caudate nucleus of Sprague-Dawley rats with stereotactic technology. The infection in the brain was observed by conventional MRI scanning on days 14, 21, and 28 of modeling. The tracer-based MRI with a gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) as a magnetic tracer was performed on the rats with cryptococcal granuloma and the rats in the control group. The parameters of ECS in each area of cryptococcal brain granuloma were measured. The parameters of ECS in the two groups were compared by independent sample t-test, and the changes in ECS and its mechanism were analyzed.

Results

Up to 28 days of modeling, the success rate of establishing the brain cryptococcal granuloma model with 1 × 10⁶ CFU/ml Cryptococcus neoformans suspension was 60%. In the internal area of cryptococcal granuloma, the effective diffusion coefficient D* was significantly higher than that of the control group (t = 2.76, P < 0.05), and the same trend showed in the volume ratio α (t = 3.71, P < 0.05), the clearance rate constant k (t = 3.137, P < 0.05), and the tracer half-life T_1/2 (t = 3.837, P < 0.05). The tortuosity λ decreased compared with the control group (t = -2.70, P < 0.05). At the edge of the cryptococcal granuloma, the D* and α decreased, while the λ increased compared with the control group (D*:t = -6.05, P < 0.05; α: t = -4.988, P < 0.05; λ: t = 6.222, P < 0.05).

Conclusion

The internal area of the lesion demonstrated a quicker, broader, and more extended distribution of the tracer, while the edge of the lesion exhibited a slower and narrower distribution. MRI tracer method can monitor morphological and functional changes of ECS in pathological conditions and provide a theoretical basis for the treatment via ECS.

Brain cryptococcoma mimicking a glioblastoma in an immunocompetent patient: A rare case report and comprehensive review

Background:

Cryptococcosis is an invasive fungal infection primarily affecting lungs and potentially spreading to the central nervous. This fungal infection might be misdiagnosed as other infection diseases, such as tuberculosis; granulomatous diseases, like sarcoidosis; and even neoplastic diseases. Some previous reports described cases of cryptococcomas resembling brain tumors. In this paper, we present a very rare presentation of brain cryptococcoma mimicking a malignant glioma. To the best of our knowledge, this is the third case description in the literature.

Case Description:

A 64-year-old male patient presented at the hospital with a history of progressive frontal headache for 1 month, becoming moderate to severe, associated with visual changes, without nausea or vomiting. No fever was reported. He was a heavy smoker and denied other relevant previous medical data. Neuroimage disclosed a right temporal expansive lesion initially considered a malignant glioma. The patient underwent a right temporal craniotomy and biopsy revealed a cryptococcoma.

Conclusion:

Cryptococcomas characteristics in magnetic resonance are quite nonspecific. They should always be included in differential diagnosis of expansive brain lesions, both malignant and benign. Therefore, once cryptococcomas may resemble like other intracranial expansive lesions, biopsy should always be carried out to clarify diagnosis and avoid inadequate treatment and definition of prognosis only based on radiological patterns.

Cerebral Cryptococcomas: A Systematic Scoping Review of Available Evidence to Facilitate Diagnosis and Treatment

Background: Recommendations for managing patients with cerebral cryptococcomas are scarce across multiple clinical guidelines. Due to the deficiency of high-quality data coupled with an increasing number of at-risk patients, the purpose of this review is to describe the demographic characteristics, causative pathogen, intracranial imaging, surgical and/or pharmacological interventions, as well as outcomes of patients with cerebral cryptococcomas to improve recognition and management. Methods: We conducted a scoping review in accordance with the PRISMA guidelines using PubMed and Web of Science. Reports were included if the following details were presented: (1) site of infection; (2) treatment details which at least include the specific antifungal therapy administered, if applicable; and (3) patient outcome. Results: A total of 40 records representing 47 individual patients were included, of which the median age was 48.5 years, 75% were male, and 60% reported a significant past medical, surgical, or social history. C. neoformans was isolated more often than C. gattii (74% vs. 26%, respectively). Patients most often presented with headache, altered mental status and/or confusion, and vomiting occurring over a median of 30 days; though few were noted to have significant findings on physical examination. More than 50% of patients had a single cerebral cryptococcoma lesion, whereas perilesional edema was present in 73% of cases. Surgical intervention occurred in 49% of patients. An amphotericin B-based formulation was administered as “induction” therapy to 91% of patients, but combined with flucytosine or fluconazole in only 58%, for an overall median of 42 days. Fifty two percent of patients received “maintenance” therapy for a median of 126 days, in which fluconazole was most often used. Corticosteroids were administered to approximately 30% of patients for a median of 31.5 days. Overall, mortality was 34%. Conclusion: Based on our findings, management should include antifungal therapy for a minimum of 6 months with considerations for concomitant corticosteroids in the setting of perilesional edema, as well as surgical intervention. Emphasis should be placed on providing well-documented treatment details in future case reports and series to allow for the development of more concise evidence-based recommendations.

Seizure in isolated brain cryptococcoma: Case report and review of the literature

Background:

Central nervous system (CNS) cryptococcosis is an invasive fungal infection predominantly seen among immunosuppressed patients causing meningitis or meningoencephalitis. Rarely, cryptococcosis can affect immunologically competent hosts with the formation of localized CNS granulomatous reaction, known as cryptococcoma. Common symptoms of CNS cryptococcoma are headaches, consciousness or mental changes, focal deficits, and cranial nerve dysfunction. Rarely, seizures are the only presenting symptom.

Case Description:

We report the case of an immunocompetent patient with a solitary CNS cryptococcoma presenting with a long history of non-responsive generalized seizure who has been successfully operated.

Conclusion:

CNS cryptococcoma is a rare entity, and in immunocompetent patients, its diagnosis can be challenging. The pathophysiology of lesion-related seizure is discussed along with a review of the pertinent literature.

Recurring Multicentric Granulomatous Cryptococcomas in the Contralateral Cerebral Hemisphere in an Adult Immunocompetent Patient with Known Previous Disease

BACKGROUND

Fungal mass lesions in the central nervous system rarely reach a size large enough to directly cause neurologic deterioration. In terms of the etiologic incidence of fungal mass lesions in the central nervous system, whereas cryptococcomas may be the most common, they rarely reach any appreciable size. One form of this specific fungal infection, namely the granulomatous form of cryptococcomatosis, challenges this paradigm, and these lesions can reach an alarming size.

CASE DESCRIPTION

We previously reported a case of multicentric granulomatous cryptococcomas occurring in an adult immunocompetent male patient published in WORLD NEUROSURGERY in mid-2018. We now report that despite confirmed gross total resection and subsequent neurologic improvement having been achieved at that time, the patient was not compliant with his prescribed adjuvant antifungal medical therapy, and for 6 months was lost to follow-up. We now report that the same patient again presented to our unit in early-2019 with recurrent granulomatous cryptococcomas, of an alarming even larger size, in the contralateral hemisphere. Fortunately, were again were able to successfully manage him surgically and have now adapted our surveillance plan to include booked follow-up magnetic resonance imaging.

CONCLUSIONS

According to our review of the English literature, to our knowledge, this is the first report of recurrent granulomatous cryptococcomas occurring in the contralateral hemisphere within 6 months of surgery. The case illustrates the importance of the adjuvant antifungal medial therapy if recurrence is to be avoided.

Intracranial Cryptococcoma-Clinicopathologic Correlation and Surgical Outcome: A Single-Institution Experience

OBJECTIVE

To describe clinical characteristics of patients with intracranial cryptococcoma, clinicopathologic findings, and outcomes after surgery.

MATERIALS AND METHODS

Clinical data were collected from hospital case records, and pathologic confirmation was done by a neuropathologist. Clinical details, imaging features, and treatment modalities were evaluated and correlated with outcomes based on regular follow-up.

RESULTS

This case series included 5 cases of histology- and culture-proven intracranial cryptococcoma. Three patients (60%) were aged between the 3rd and 5th decades. Three cases were supratentorial in location, and 2 were in the posterior fossa. One patient presented with seizures. Three patients (60%) presented with fever. Three patients (60%) had papilledema, and 4 (80%) had signs of meningeal irritation. Four patients (80%) were immunocompetent. Only 1 patient was immunocompromised. All lesions were peripherally enhancing on computed tomography. Four of 5 patients underwent surgical decompression without any residue. Only 1 patient underwent stereotactic biopsy. All patients received antifungal therapy. One patient who was immunocompromised developed multiorgan failure and died after 2 months after surgery (20%). Of 5 cases, 4 (80%) had a good outcome with a mean follow-up of 5 years.

CONCLUSIONS

Cryptococcus gattii is a rarer species implicated in intracranial cryptococcoma that is seen along with the more common Cryptococcus neoformans. Early diagnosis and surgical decompression followed by intravenous amphotericin B therapy for at least 6 weeks and concomitant therapy with fluconazole for prolonged periods may reduce morbidity and mortality.