Cryptococcal Brainstem Abscess Mimicking Brain Tumors in an Immunocompetent Patient

Usually fungal infections caused by opportunistic and pathogenic fungi had been an important cause of morbidity and mortality among immunocompromised patients. However clinical data and investigations for immunocompetent pathogenic fungal infections had been rare and neglected into clinical studies. Especially Cryptococcal brainstem abscess cases mimicking brain tumors were also much more rare. So we report this unusual case. This 47-year-old man presented with a history of progressively worsening headache and nausea for 1 month and several days of vomituritions before admission. Neurological and laboratory examinations performed demonstrated no abnormal findings. Previously he was healthy and did not have any significant medical illnesses. A CT and MRI scan revealed enhancing 1.8x1.7x2.0 cm mass lesion in the left pons having central necrosis and peripheral edema compressing the fourth ventricle. And also positron emission tomogram scan demonstrated a hot uptake of fluoro-deoxy-glucose on the brainstem lesion without any evidences of systemic metastasis. Gross total mass resection was achieved with lateral suboccipital approach with neuronavigation system. Postoperatively he recovered without any neurological deficits. Pathologic report confirmed Cryptococcus neoformans and he was successively treated with antifungal medications. This is a previously unreported rare case of brainstem Cryptococcal abscess mimicking brain tumors in immunocompetent host without having any apparent typical meningeal symptoms and signs with resultant good neurosurgical recovery.

The Analysis of Primary Origin in Spinal Metastasis Occurring as the Initial Manifestation of Malignancy

OBJECTIVE: The objective of this study is to delineate clinical features and specific diagnostic and therapeutic implications of spinal metastasis occurring as the initial manifestation of malignancy(SM-IMM)-a less common event than spinal metastasis in the setting of previously established malignancy(SM-PEM). METHODS: The authors reviewed retrospectively the clinical records of 19 patients in SM-IMM group at Korean Cancer Center Hospital between January 1, 2000 and December 31, 2001 and analyzed symptom duration, primary origin, treatment modality and survival time. Then 287 cases of SM-PEM group were searched for primary origin. RESULTS: Thyroid cancer(36.8%), metastasis of unknown origin(31%), liver cancer(10.5%) and stomach cancer (10.5%) were found as primary tumor in SM-IMM group. But in SM-PEM group lung cancer was most frequent primary tumor(22%), breast cancer(17%), stomach cancer(7.3%) and liver cancer (7.3%) followed. Primary pathology was confirmed with spinal decompressive surgery(7 cases), biopsy of spinal lesion(5 cases), and biopsy of other sites except spine(7 cases). Patients in SM-IMM group showed short symptom duration and multi-segmental involvement at diagnosis. And post-treatment survival time was short except thyroid cancer in spite of aggressive treatment(mean survival time, 2.7 months). CONCLUSION: SM-IMM group showed different profile from SM-PEM group on primary origin. And in the diagnosis of primary origin in SM-IMM group, important clues were provided with history taking, physical examination and PET.

Postoperative Brain Abscess Caused by Co-Infection of Aspergillus and Staphylococcus: Case Report

A staphylococcal brain abscess admixed with aspergillosis occurred after operation for the olfactory groove meningioma at remote site. We report the rare case and consider the clinical pathogenesis. Bifrontal craniotomy for the olfactory groove meningioma was done in a 61-year-old female. She was bedridden for one month after craniotomy. During that period, panhypopituitarism occurred and was corrected with hormonal replacement. Sore in the occipital scalp which had occurred during the bedridden state was cared by dressing. After 60 days of treatment, he was discharged with ambulatory status. During postoperative period, we found left parieto-occipital brain abscess in the brain computed tomography(CT) at 3 months. And then craniotomy and abscess resection was performed. Vancomycin and itraconazole antibiotic therapy was instituted after the identification of staphylococcus and aspergillus in the cystic fluid, and aspergillus hyphae in the solid wall portion of the abscess. After the confirmation of resolution of brain abscess on the postoperative 3 weeks' brain CT, the patient was discharged with oral itraconazole medication.