Neuroaspergillosis in an immunocompetent patient successfully treated with voriconazole and a corticosteroid

A Rare Case of Invasive Central Nervous System Aspergillus niger in a Previously Immunocompetent Patient After Corticosteroid Treatment for COVID-19

Aspergillus is a ubiquitous saprophyte found in air, soil, and organic matter. Humans inhale the spore form of the fungus, but manifestations of the disease are typically predominantly seen in immunocompromised patients. Invasive central nervous system (CNS) aspergillosis is even more uncommon, and epidemiological data is sparse, particularly in immunocompetent patients. We report the case of a 67-year-old previously immunocompetent female with no known comorbidities who was treated with corticosteroids for COVID-19 one month prior to admission for altered mental status (AMS). Subsequent imaging and biopsy demonstrated invasive CNS Aspergillus niger. Though a rare cause of AMS in immunocompetent patients, this report draws attention to the detrimental immunosuppressive effects of corticosteroid therapy in COVID-19.

Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review

The clinical features and prognostic factors of intracranial aspergillosis in immunocompetent patients without risk factors are not well known. PubMed, Scopus, Google Scholar, and Web of Science were searched for all relevant case reports/series on adult patient (≥ 18 years) with aspergillosis published from 1976 to 2018. One hundred eighty-two patients (median age, 40 years; range, 18-83 years; male:female, 115:67) were identified. Types of intracranial aspergillosis included intracranial mass from the skull base (54.9%), pure intraparenchymal disease (23.6%), meningoencephalitis (13.2%), and dural-based mass (8.2%). Vascular complications occurred in 44 patients (26.3%). Eighty-one patients (44.5%) had favourable final clinical outcomes without any deficits, whereas 58 (31.9%) died. Disease-related mortality improved significantly over time (43.1% [28/65] before 2000, 25.9% [30/116] after 2001; p = 0.021). Patients with meningoencephalitis demonstrated the highest mortality rate (79.2%, 19/24). Medical non-responders (patients whose disease course worsened after receiving the initial medication regimen) and vascular complications (the presentation of subarachnoid haemorrhage, intracerebral haemorrhage, or infarction related to the rupture or occlusion of intracranial vessels) were significantly associated with mortality (p < 0.001). Findings from the current review may help predict patient prognosis at the initial assessment and determine potential prognostic factors.

Impact of Surgical and Medical Treatment on Survival of Patients with Cerebral Aspergillosis: Systematic Review of the Literature

OBJECTIVE

Cerebral aspergillosis carries a high mortality. Rapid diagnosis and treatment can increase survival, but symptoms and imaging findings are nonspecific. The literature on cerebral aspergillosis consists mostly of case reports and case series and lacks large-scale review of data.

METHODS

We performed a review of the literature using PubMed in March 2019. We recorded the year of publication, age and sex of patients, neurosurgical involvement, the antifungals administered, use of intrathecal antifungals, and the outcome of patients. The relationships among variables were tested using bivariant statics and linear regression.

RESULTS

A total of 324 studies met the eligibility criteria, and 198 studies including 248 patients were included. Surgical resection (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.25-0.80; P < 0.01) and administration of voriconazole (OR, 0.32; 95% CI, 0.18-0.55; P < 0.001) or itraconazole (OR, 0.36; 95% CI, 0.16-0.72; P < 0.001) were shown to be significantly associated with survival.

CONCLUSIONS

Given the significant survival benefits for patients who received voriconazole and surgical intervention, we suggest early antifungal medical treatment and resection.

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.

Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Background:

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

Case report:

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Conclusion:

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

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.

Fatal case of cerebral aspergillosis : a case report and literature review

Cerebral aspergillosis is rare and usually misdiagnosed because its presentation is similar to that of a tumor. The correct diagnosis is usually made intra-operatively. Cerebral abscess with fungal infection is extremely rare and few cases have been reported, but it carries a poor prognosis.

A 73 year-old man presented with decreased visual acuity and paresis of the right cranial nerve III. Magnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extened to the anterior crainial fossa and the superior orbital fissure. During surgery, a well encapsulated pus pocket was found, and histopathological examination of the mass resulted in the diagnosis of aspergillosis. Despite appropriate anti-fungal treatment, the patient eventually died from fatal cerebral ischemic change and severe brain swelling.

The correct diagnosis of cerebral aspergillosis can only be achieved by histopathological examination because clinical and radiological findings including MRI are not specific. Surgical intervention and antifungal therapy should be considered the optimal treatment. Early diagnosis and aggressive antifungal treatment provide good results.

Invasive fungal infection of the central nervous system in a patient with acute myeloid leukaemia

Background:

Although the new intensive chemotherapeutic programs introduced recently into hematooncological therapies have led to a higher number of recoveries, persistent neutropenia favours the spread of severe infections, frequently fungal infections. Systemic fungal infections in patients treated for proliferative diseases of the hematopoietic system are characterised by a severe, progressing course and high morbidity.

Case Reports:

We present a case report that demonstrates the diagnostic problem of lesions in the central nervous system which developed following the fourth block of chemotherapy in an eight-year-old boy treated for acute myeloid leukaemia. The risk factors, high values of the inflammatory parameters and imaging results enabled us to diagnose a fungal infection of the central nervous system.

Results:

A fast improvement in the clinical condition of the patient after the applied antifungal therapy and the regression of lesions in the central nervous system shown in the imaging studies confirmed our final diagnosis.

Imaging findings in intracranial aspergillus infection in immunocompetent patients

AIM

To study the neuroimaging features of craniocerebral aspergillosis infection in immunocompetent patients.

MATERIALS AND METHODS

The clinical and imaging data of 12 patients of aspergillus fungal infection were retrospectively reviewed. Diagnosis of fungal infection was confirmed by histopathologic examination of surgically excised specimen, stereotactic biopsy material, or endoscopic sinus biopsy. The radiologic studies were evaluated for anatomic distribution of lesions, signal intensity, contrast enhancement, presence of hemorrhage, diffusion restriction, perfusion, and spectroscopy characteristics. Medical records, biopsy reports, and autopsy findings were also reviewed.

RESULTS

Twelve cases of aspergillosis infections in immunocompetent patients were diagnosed at our hospital over a period of 10 years. Lesions could be classified based on imaging of lesions of sinonasal origin, intracranial mass lesion including both parenchymal or extraparenchymal meningeal based and stroke. Coexisting meningitis was also noted in one patient. Disease of sinonasal origin commonly showed invasion of the cavernous sinus and orbital apex resulting in visual symptoms and multiple cranial nerve palsies. Intracranial mass lesions without sinonasal involvement were seen in five cases that included isolated parenchymal lesion in two patients and dural-based mass lesions in three patients. Isolated intraparenchymal lesions included two cases of fungal cerebritis. Dural-based lesions were large granulomas with a significant mass effect. Infarcts were seen in three patients and angiography showed vessel narrowing or occlusion in all the three patients. CT demonstrated isodense to hyperdense attenuation of primary sinus disease with evidence of bone destruction in all the cases of sinonasal origin. Primary parenchymal lesions showed heterogenous attenuation with predominantly low-density areas. Dural-based lesions showed isodense to hyperdense attenuation. Magnetic resonance imaging revealed isointense to hypointense signal intensity on both T(1)-weighted (T1W) and T(2)-weighted (T2W) images in all lesions of sinonasal origin and isolated dural-based mass lesions. Primary parenchymal lesions showed heterogenous signal intensity pattern with predominantly hypointense signal on T1W and hyperintense signal on T2W images. Diffusion weighted imaging, magnetic resonance spectroscopy, and perfusion-weighted imaging gave valuable ancillary information in these cases.

CONCLUSION

Sinonasal disease with intracranial extension is the commonest pattern of aspergillus infection followed by intracranial mass lesions. Hyperdense sinonasal disease with bone destruction and intracranial extension on computed tomography, hypointense signal intensity of the lesions on T2W magnetic resonance images, presence of areas of restricted diffusion, decreased perfusion on perfusion-weighted imaging, and presence of hemorrhages are key to the imaging diagnosis of fungal infection.