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Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain.
World Neurosurg. 2020 Feb; 134:170-175.WN

Abstract

BACKGROUND

Invasive aspergillosis of the central nervous system, a saprophytic infection with a unique vascular tropism, carries the burden of increased morbidity and mortality. Early clinical and imaging findings can masquerade as an innocuous condition before a secondary inexorable progression. We highlight the clinical and imaging phenotype of a patient with fatal invasive granulomatous aspergillosis.

CASE DESCRIPTION

A 39-year-old man presented with progressive weakness of the left upper and lower limb for 4 months. Imaging demonstrated right holohemispheric extensive, numerous, confluent, ill-defined, T2 hypointense foci with moderate perilesional edema. Numerous foci of microhemorrhages with cortical asymmetric mineralization were seen. Post-contrast heterogeneous, variegate, punctiform enhancement of the lesions was observed extending to the ventricular margins. Volume loss of the left cerebral peduncle and ipsilateral long white matter descending tracts was noted. Histopathologic examination of a stereotactic biopsy specimen from the frontal region lesion showed dense inflammatory infiltrate with granulomas, a few in a perivascular distribution and branching septate hyphae resembling Aspergillus. The patient was initiated on antifungal therapy and in the following week, he had progressive drowsiness. The patient succumbed the next day.

CONCLUSIONS

Diffuse holohemispheric, progressive presentation of a granulomatous form of invasive aspergillosis is a rare entity. The miliary pattern of heterogenous enhancement, holohemispheric conglomerate T2 hypointensities, interspersed hemorrhage, juxtacortical punctate T2 hyperintense foci, low perfusion, and the relative absence of diffusion abnormality are distinctive features. Early diagnosis of this atypical imaging phenotype of Aspergillus infection and appropriate treatment is critical for better prognosis.

Authors+Show Affiliations

Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India.Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, India. Electronic address: chandrajitt2@gmail.com.Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India.Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, India.

Pub Type(s)

Case Reports

Language

eng

PubMed ID

31562969

Citation

Kulanthaivelu, Karthik, et al. "Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain." World Neurosurgery, vol. 134, 2020, pp. 170-175.
Kulanthaivelu K, Prasad C, Kumar Reddy YV, et al. Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain. World Neurosurg. 2020;134:170-175.
Kulanthaivelu, K., Prasad, C., Kumar Reddy, Y. V., & Mahadevan, A. (2020). Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain. World Neurosurgery, 134, 170-175. https://doi.org/10.1016/j.wneu.2019.09.100
Kulanthaivelu K, et al. Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain. World Neurosurg. 2020;134:170-175. PubMed PMID: 31562969.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain. AU - Kulanthaivelu,Karthik, AU - Prasad,Chandrajit, AU - Kumar Reddy,Yerasi Varun, AU - Mahadevan,Anita, Y1 - 2019/09/25/ PY - 2019/08/21/received PY - 2019/09/17/revised PY - 2019/09/18/accepted PY - 2019/9/29/pubmed PY - 2020/3/11/medline PY - 2019/9/29/entrez KW - Cerebritis KW - Fungal KW - Granuloma KW - Hematogenous KW - Holohemispheric KW - Invasive SP - 170 EP - 175 JF - World neurosurgery JO - World Neurosurg VL - 134 N2 - BACKGROUND: Invasive aspergillosis of the central nervous system, a saprophytic infection with a unique vascular tropism, carries the burden of increased morbidity and mortality. Early clinical and imaging findings can masquerade as an innocuous condition before a secondary inexorable progression. We highlight the clinical and imaging phenotype of a patient with fatal invasive granulomatous aspergillosis. CASE DESCRIPTION: A 39-year-old man presented with progressive weakness of the left upper and lower limb for 4 months. Imaging demonstrated right holohemispheric extensive, numerous, confluent, ill-defined, T2 hypointense foci with moderate perilesional edema. Numerous foci of microhemorrhages with cortical asymmetric mineralization were seen. Post-contrast heterogeneous, variegate, punctiform enhancement of the lesions was observed extending to the ventricular margins. Volume loss of the left cerebral peduncle and ipsilateral long white matter descending tracts was noted. Histopathologic examination of a stereotactic biopsy specimen from the frontal region lesion showed dense inflammatory infiltrate with granulomas, a few in a perivascular distribution and branching septate hyphae resembling Aspergillus. The patient was initiated on antifungal therapy and in the following week, he had progressive drowsiness. The patient succumbed the next day. CONCLUSIONS: Diffuse holohemispheric, progressive presentation of a granulomatous form of invasive aspergillosis is a rare entity. The miliary pattern of heterogenous enhancement, holohemispheric conglomerate T2 hypointensities, interspersed hemorrhage, juxtacortical punctate T2 hyperintense foci, low perfusion, and the relative absence of diffusion abnormality are distinctive features. Early diagnosis of this atypical imaging phenotype of Aspergillus infection and appropriate treatment is critical for better prognosis. SN - 1878-8769 UR - https://www.unboundmedicine.com/medline/citation/31562969/Holohemispheric_Invasive_Aspergillus_Granulomatous_Cerebritis_of_the_Brain L2 - https://linkinghub.elsevier.com/retrieve/pii/S1878-8750(19)32531-8 DB - PRIME DP - Unbound Medicine ER -