Aspergilosis cerebral como causa de lesión cerebral focal asociada SIDA: a propósito de un caso y revisión de la literatura / Focal brain lesion due to cerebral aspergillosis in a patient with AIDS: case report and literature review

Resumen La aspergilosis cerebral es una patología infrecuente, pero de elevada mortalidad en pacientes con SIDA. Es importante considerarla entre los diagnósticos diferenciales ante una lesión expansiva cerebral. Se requiere un alto grado de sospecha para poder realizar un diagnóstico precoz. Se presenta el caso de un paciente con infección por VIH con un cuadro neurológico rápidamente progresivo por Aspergillus sección flavi. Se realiza una revisión de 40 casos publicados de aspergilosis cerebral en pacientes con SIDA.

Cerebral aspergillosis is a rare disease with high mortality rates in AIDS patients. It is important to take this into account in the differential diagnosis of a brain expansive lesion. A high level of suspicion is required to make an early diagnosis. We present a case of an HIV-infected patient with progresive neurological disease caused by Aspergillus flavi. We review 40 previously published cases of central nervous system aspergillosis in patients with AIDS.

Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient

Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly found in immunocompromised patients but rarely seen among immunocompetent patients. Herein we describe a 57 year-old immunocompetent man who suffered intracranial aspergillosis spread by the pterygopalatine fossa (PPF) following a tooth extraction. Based on magnetic resonance imaging (MRI) characteristics, in this report we focus on the spreading routes of CNS aspergillosis via communicative structures of the PPF, the relationship between clinical manifestations and the locations of the lesion, and propose a therapeutic strategy to improve the prognosis.

Importancia de las imágenes y el diagnóstico etiológico en el paciente inmunocomprometido con afección del SNC / Importance of images and etiological diagnosis of central nervous system envolvement in immunocompromised patient

We report a 16 years old boy with diagnosis of Acute Myeloid Leukemia with severe immune suppression secondary to his primary disease and to leukemia's treatment. Early during the course of his chemotherapy he developed symptoms and signs compatible with invasive fungal disease (IFD). Lungs were primarily compromised followed by CNS involvement with manifestations of intracranial hypertension. Laboratory exams were remarkable for prolonged neutropenia and indirect evidence of Aspergillus sp infection, with successive detection of positive and increasing levels of galactoman antigen in serum. With this case we want emphasize the great importance of invasive fungal disease in immune suppressed patients and particularly the CNS compromise. This represents a medical emergency which deserves to start a complete and comprehensive microbiology diagnosis and concomitantly start an empiric antifungal treatment. The importance of neuroimaging for a correct identification of the number, location and size of CNS lesions must be highlighted. The election of MRI, if available, should be preferred due to a better performance than CT scan. Brain biopsy should be discussed when all the non invasive attempts for etiology identification have failed. The invasive fungal CNS compromise has medical treatment and the surgical drainage has to be considered for lesions greater than 2 cm or for those making a mass effect or have failed with medical treatment.

Comunicamos el caso de un adolescente de 16 años, con una leucemia mieloide aguda y una grave inmunosupresión secundaria a su enfermedad y el tratamiento. Precozmente post-quimioterapia desarrolló síntomas y signos compatibles con una enfermedad fúngica invasora (EFI). Inicialmente se afectaron sus pulmones y a continuación el SNC con hipertensión intracraneal. Los exámenes de laboratorio indicaron una neutropenia prolongada y evidencias indirectas de una infección por Aspergillus sp mediante la medición sucesiva de galactomanano positivo en sangre y un segundo valor en ascenso. Con este caso enfatizamos la gran importancia que tienen las EFI en pacientes inmunocomprometidos, particularmente sobre el SNC. Ellas representan una emergencia médica que requiere de una confín-nación microbiológica y el inicio temprano de terapia anti-fúngica empírica. Debe destacarse la importancia que tienen las neuro-imágenes en la correcta identificación del número de lesiones, su localization y tamaño. La RM, si está disponible, debiera ser la elección, para una mejor definición, por sobre el uso de la TAC. Igualmente, debiera discutirse la indicación de biopsia cerebral cuando todos los métodos no invasores han fracasado en precisar la etiología. La EFI del SNC es de tratamiento médico, debiéndose considerar el drenaje quirúrgico de las lesiones con más de 2 cm de diámetro o aquellas que ejercen efecto de masa o, finalmente, cuando ha fracasado el manejo con anti-fúngicos.

Aspergilose do sistema nervoso central após transplante hepático. Relato de caso / Cerebral aspergillosis in a liver transplanted patient. Case report

Introdução: O acometimento do sistema nervoso central pelo Aspergillus é muito grave e com alto índice de mortalidade. Relato de caso: Descrevemos o caso de uma paciente transplantada hepática em uso de imunossupressores que evoluiu com piora clínica. Tomografia computadorizada e ressonância magnética revelaram múltiplas lesões cerebrais. Em decorrência de má condição clínica da paciente, optou-se pelo tratamento conservador e em três dias ela evoluiu para óbito. Estudo anatomopatológico constatou quadro compatível com aspergilose. Discussão: Em pacientes imunossuprimidos, a suspeita precoce da infecção central fúngica é essencial para tentar evitar uma evolução catastrófica como no caso relatado.

Cerebral aspergillosis presenting as a mass lesion

Fungal infections of the central nervous system (CNS) are almost always a surprising finding. Their presentation is usually subtle, often without any diagnostic characteristics, and they are frequently mistaken for pyogenic abscesses, or brain tumors. Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients. It may present in several forms, including meningitis, mycotic aneurysms, infarcts and a tumoral form. We report an intracranial granuloma due to Aspergillus fumigatus involving the anterior cranial fossa and the frontal lobe. The clinical symptoms began one year before admission. Final diagnosis was made after craniotomy. The patient was treated with an extensive excision of the cerebral mass and medical antifungal therapy (intravenous amphotericin B), but she failed to respond to these treatments and died.

Aspergilose cerebral em paciente imunocompetente / Cerebral Aspergillus abscess in immunocompetent patient

Descrevemos um caso raro de aspergilose cerebral, como complicação de cirurgia para aneurisma cerebral, em paciente imunocompetente, e com sucesso no tratamento. A paciente, de 40 anos, havia sido submetida a craniotomia para clipagem de aneurisma da artéria pericalosa. Após cinco meses, no sitio cirúrgico, surgiram múltiplos abscessos por Aspergillus sp. Foram necessárias duas craniotomias para a retirada da massa fúngica e uso de anfotericina B. Após 14 anos de acompanhamento, a evolução mostra resolução da aspergilose, sem seqüela. O tratamento do abscesso cerebral por Aspergilus exige acompanhamento clínico contínuo, repetidas drenagens cirúrgicas intracranianas e o uso de anfotericina B no tratamento medicamentoso.

Invasive aspergillosis producing painful ophthalmoplegia.

Painful ophthalmoplegia is caused by the lesions of orbital apex and anterior cavernous sinus. Cavernous sinus syndrome can be produced by intracranial invasive aspergillosis. A case of painful ophthalmoplegia due to invasive aspergillosis caused by Aspergillus niger in a diabetic patient is presented.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA.

Central nervous system fungal infection--a report of three cases.

Fungal infections of the central nervous system in three apparently immunocompetent patients are being reported. Two cases of cerebral aspergillosis presenting as intracranial granulomas such as rhinocerebral and intracranial forms, and one of cryptococcal meningitis could be successfully diagnosed by newer diagnostic modality such as antigen detection techniques. The case with cryptococcal infection had typical neuroimaging feature which helped to suspect the underlying diagnosis. Aspergillus galactomannan detection in the cerebrospinal fluid helped in the early diagnosis and appropriate therapy of one patient.

Aspergillosis of the central nervous system: a catastrophic opportunistic infection.

The clinical features and outcome of the treatment of aspergillosis of the central nervous system (CNS) in Thai patients are presented. The patients who were diagnosed as having CNS aspergillosis by tissue biopsy or culture from January 1, 1991 to December 31, 2000 were retrospectively reviewed. The study variables including age, sex, underlying disease, symptoms and signs, neuro-imaging studies, pathological findings and outcome of treatment, are described. There were seven cases of aspergillosis of the central nervous system. Four patients were male. The median age was 65 years (range 36-78 years). The most common underlying disease was diabetes mellitus (4/7; 57.1%). Two patients (28.6%) had no underlying disease. The most common primary site of infection was the paranasal sinuses (6/7; 85.7%). The most common clinical presentation was headache (6/7; 85.7%). Common neurological signs included multiple cranial nerve palsies (5/7; 71.4%) and alteration of consciousness (3/7; 42.9%). The median duration of the symptoms prior to admission was 60 days (range 8-180 days). All patients were treated with intravenous antifungal agents at high doses. Extensive surgery was performed in 6 patients. The mortality rate was very high (6/7; 85.7%). The median time from diagnosis and treatment to death was 53 days (22-720 days). Aspergillosis of the CNS should be considered in those with clinical features of headache, multiple cranial nerve palsies and alteration of consciousness accompanied by sinusitis, especially in elderly and diabetic patients. It remains a catastrophic opportunistic infection in spite of the current intensive and aggressive treatment.