ABSTRACT
We report a case of cerebral phaeohyphomycosis, a fungal brain infection due to a dark (dematiaceous) fungi in a 6-year-old French Guyanese boy. The child presented fever and drowsiness due to several paraventricular brain abscesses. Neurological surgeries were performed to reduce intracranial hypertension and to obtain abscess biopsies. Mycological cultures of intraoperative samples led to the diagnosis of cerebral phaeohyphomycosis due to Cladophialophora bantiana. The patient neurological status deteriorated and remained critical after several weeks of combination antifungal therapy with voriconazole 8mg/kg/day, liposomal amphotericin B 10mg/kg/day and flucytosine 200mg/kg/day. A complete surgical resection was not possible because of multiple small abscesses. A multidisciplinary ethical staff decided on home medical care with palliative ventriculoperitoneal shunt, nasogastric feeding and analgesics. One year later, the patient's neurological condition had improved and cerebral lesions had regressed, while he had not received any antifungal treatment but only traditional medicines. Cerebral phaeohyphomycosis are rare diseases affecting immunocompromised but also apparently non-immunocompromised patients, as in this case. A complete surgical resection is not always possible and mortality rates are high in spite of treatments with a combination of antifungals. The diagnosis may be difficult because of these dematiaceous fungi's slowly growing and their potential pathogenicity for laboratory staff.
Subject(s)
Ascomycota/isolation & purification , Central Nervous System Fungal Infections/diagnosis , Cerebral Phaeohyphomycosis/diagnosis , Antifungal Agents/therapeutic use , Ascomycota/physiology , Brain Abscess/diagnosis , Brain Abscess/microbiology , Brain Abscess/therapy , Central Nervous System Fungal Infections/microbiology , Central Nervous System Fungal Infections/therapy , Cerebral Phaeohyphomycosis/microbiology , Cerebral Phaeohyphomycosis/therapy , Child , Combined Modality Therapy , Enteral Nutrition , French Guiana , Humans , Immunocompetence , Intubation, Gastrointestinal , Male , Neurosurgical Procedures , Ventriculoperitoneal ShuntABSTRACT
Cladophialophora bantiana brain abscess is a rare and frequently fatal infection, often seen in immunocompetent individuals. 34 year old immunocompetent woman who presented with convulsions is reported. She was initially treated with antituberculous drug. During 15 days of treatment, she deteriorated. Hence she underwent craniotomy, which revealed brain abscesses due to C. bantiana. Subsequently she was treated with fluconazole , but eventually succumbed to the infection on the 7th day of treatment. Mortality remains high with this rare mycosis, even in immunocompetent patients. The case illustrates the clinical and radiological similarities between tuberculoma and other etiologies of brain abscesses. This emphasizes the need to perform histological and microbiological studies prior to the initiation of any form of therapy.
Subject(s)
Ascomycota/isolation & purification , Brain Abscess/diagnosis , Brain Abscess/pathology , Cerebral Phaeohyphomycosis/diagnosis , Cerebral Phaeohyphomycosis/pathology , Early Diagnosis , Adult , Antifungal Agents/therapeutic use , Brain/diagnostic imaging , Brain Abscess/microbiology , Brain Abscess/therapy , Cerebral Phaeohyphomycosis/microbiology , Cerebral Phaeohyphomycosis/therapy , Craniotomy , Fatal Outcome , Female , Fluconazole/therapeutic use , Humans , Magnetic Resonance Imaging , Microbiological Techniques , Microscopy , RadiographyABSTRACT
CASE DESCRIPTION: A 12-month-old castrated male Boxer was examined because of signs of acute, progressive intracranial disease. CLINICAL FINDINGS: Cytologic and histologic findings were consistent with an intracranial fungal granuloma in the right cerebral hemisphere. Fungal culture yielded a Cladophialophora sp. TREATMENT AND OUTCOME: The granuloma was surgically debulked to remove infected brain tissue and the avascular purulent core. Postoperatively, the patient was treated with fluconazole (2.3 mg/kg [1 mg/lb], PO, q 12 h) for 4 months, followed by voriconazole (3.4 mg/kg [1.5 mg/lb], PO, q 12 h) for a further 10 months. The outcome was considered excellent on the basis of resolution of neurologic signs and a lack of evidence of recurrence of the granuloma during magnetic resonance imaging and CSF analysis 8 months after surgery. Magnetic resonance imaging and CSF analysis 9 weeks after administration of antifungal medications was discontinued (16 months after surgery) confirmed resolution. CLINICAL RELEVANCE: Intracranial phaeohyphomycosis in small animals is rare and is most commonly associated with Cladophialophora infection. Phaeohyphomycosis frequently causes a focal granuloma, whereas other fungal infections typically cause diffuse meningoencephalitis. In all previous reports of phaeohyphomycosis of the CNS in dogs, treatment has been limited to medical management with conventional antifungal drugs and had failed to prevent death. The present report suggested that combined management of granulomas with surgery and newer triazole medications such as voriconazole may represent a novel strategy that improves the prognosis for this disease.
