Invasive pulmonary aspergillosis with brain dissemination in an immunocompetent host

Invasive aspergillosis is an uncommon infection, which is mainly seen among immunocompromised patients. In recent years, cases of aspergillosis involving immunocompetent hosts are increasingly being reported. Herein, we report the case of a 27-year-old man with fever, productive cough, shortness of breath, and left hemiparesis. He had suffered trauma to his head 25 days prior. Imaging of the chest showed bilateral cavitary lesions in the lungs, and neuroimaging revealed a space-occupying lesion in the right frontoparietal cerebrum. He was suspected of having an abscess or metastasis. He died on day 3 of hospitalization, and an autopsy was performed. The autopsy revealed the cause of death to be invasive pulmonary aspergillosis, with brain dissemination. Invasive aspergillosis is uncommon in apparently immunocompetent individuals, and we discuss the autopsy findings in detail.

Aspergilosis cerebral en un paciente postrasplante cardiaco: reporte de caso / Brain Aspergilosis after Cardiac Transplant: Case Report

RESUMEN Los pacientes trasplantados son susceptibles a complicaciones neurológicas derivadas entre otros aspectos, de las complicaciones mismas del procedimiento, el cuidado crítico que requieren los pacientes, y de los efectos secundarios a los medicamentos utilizados y el efecto inmunoderpresor de los mismos. Este último hace que los pacientes estén expuestos a infecciones oportunistas. Dentro de estas, las Infecciones del Sistema Nervioso Central en el paciente trasplantado constituyen un reto diagnóstico. Dentro de los procesos infecciosos es importante tener en cuenta aquellos relacionados con hongos, especialmente en los 3 primeros meses posterior al trasplante. Se presenta el caso de un paciente 67 años con antecedente de trasplante cardíaco, quien ingresa con un proceso febril y posterior compromiso neurológico.

SUMMARY Transplanted patients are susceptible to neurological complications arising, among other things, from the complications of the procedure itself, the critical care, and the side effects to the medications used and the immunodepressive effect thereof. It's causes patients to be exposed to opportunistic infections. Within these, Central Nervous System Infections in the transplanted patient constitute a diagnostic challenge. Within infectious processes it is important to take into account those related to fungi, especially in the first 3 months after transplantation. We present the case of a 67 years old patient with a history of heart transplantation, which enters with a febrile process and subsequent neurological compromise.

Paradoxical Response after a Voriconazole Treatment in an Immunocompetent Host with a Skull Base Osteomyelitis due to Invasive Aspergillosis

BACKGROUND: We describe a case of skull base osteomyelitis due to invasive aspergillosis which had been aggravated after antifungal treatment but significantly recovered by dexamethasone. CASE REPORT: A 74-year-old male patient presented to neurology clinic complaining of sudden onset right-sided facial palsy and headache. Brain magnetic resonance imaging (MRI) and sphenoid sinus biopsy confirmed Aspergillus infection of skull base. He was treated with voriconazole for two months, but his headache was not relieved, and he additionally complained of vertigo and dysphagia. A subsequent MRI showed reduced enhancement of initial lesions, but increased thickness of surrounding dura mater. With an impression of paradoxical inflammatory response after antifungal treatment, parenteral dexamethasone was administered for one month while maintaining voriconazole. His symptoms improved thereafter. CONCLUSION: A paradoxical inflammatory response during antifungal treatment in the skull base aspergillosis aggravates the neurological symptom by thickening the dura mater, which can be recovered by dexamethasone.

Aspergillosis of Central Nervous System in Immunocompetent Host / 계명의대학술지

Aspergillosis of the central nervous system from sinonasal origin is rare in immunocompetent hosts. Due to the rarity of the cases in immunocompetent hosts, only few cases are reported in the previous literature. But, some cases reported diversity of clinical presentations in immunocompetent hosts. Aspergillosis of the central nervous system from sinonasal origin, bony invasion with only orbit or cranial base was more common than intracerebral aspergillosis in immunocompetent hosts. In this type of disease, although maxillary sinus is more commonly involved, sphenoid sinus and clivus are unusual sites for aspergillosis of central nervous system. Because of the anatomical position of sphenoid sinus, it is associated with poor prognosis with intracranial extension. We reported a case of the aspergillosis of central nervous system involving clivus in the immunocompetent host who was misdiagnosed as metastatic tumor or plasmacytoma due to the unusual location and host factor.

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.

Aspergillus-Associated Cerebral Aneurysm Successfully Treated by Endovascular and Surgical Intervention with Voriconazole in Lupus Nephritis Patient

During the last five decades, long-term therapy with immunosuppressive agents such as pulse cyclophosphamide in conjunction with high-dose corticosteroids has enhanced both patient survival and renal survival in patients with diffuse proliferative lupus nephritis. Nevertheless, severe side effects such as infectious complications remain the main cause of morbidity and mortality. Central nervous system aspergillosis is uncommon but life-threatening in lupus patients. In this single-patient case study, carotid aneurysm with sphenoidal sinusitis was suspected when severe epistaxis occurred during cyclophosphamide pulse therapy. With anti-fungal therapy, a graft stent was successfully deployed to the aneurysm and specimens of sphenoidal mucosa showed typical hyphae, indicating aspergillosis. Three months after stopping voriconazole treatment, two cerebral aneurysms that were revealed on MR images were successfully removed by aneurysmal clipping. The patient remained alive at one-year follow-up with lupus nephritis in remission. The rarity and high mortality of aspergillus-related fungal aneurysms have led to most cases being recognized postmortem. However, such aneurysms must be diagnosed early to prevent fatal complications by performing appropriate management such as surgical procedure or endovascular intervention.

A Case of Aspergillosis of the Central Nervous System in an Immunocompetent Patient / 대한내과학회지

Invasive aspergillosis usually does not occur in immunocompetent patients. Recently, however, the incidence of invasive aspergillosis has been increasing in immunologically competent patients. It is difficult to diagnose neuroaspergillosis because of its varied radiological findings and clinical manifestations. We report a case of aspergillosis of the central nervous system, presenting as a mass-like lesion, in an immunocompetent patient. The patient was diagnosed after a surgical biopsy and treated with antifungal agents. The clinical outcome was good.

A Case of Aspergillus Epidural Abscess in Middle Cranial Fossa / 대한이비인후과학회지

Aspergillosis of the central nerve system is a rare disease, and intracranial fungal epidural abscess has not previously been described. We had been referred a 63-year old man who had 4 months history of hearing difficulty on his left ear and 3 months history of headache. Effusion of left middle ear was identified by otoscopy and tympanocentesis. Temporal bone CT showed soft tissue densities in middle ear, mastoid antrum and air cells with normal bony contours. T1 and T2-weigted MRI showed low signal intensity and peripheral rim enhancement after administration of gadolinium. Drainage of abscess through transmastoid approach was performed. Biopsy specimen showed septated fungal hyphae with Grocott's methanamine silver (GMS) and Periodic acid-schiff (PAS) stains. The authors hereby report a case of aspergillus epidural abscess of the middle cranial fossa.