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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 5 | Page : 551-552
A case of cerebral pheohyphomycosis in an immunocompetent patient: Emphasis on intraoperative findings
Ashish Aggarwal1, Pravin Salunke1, Sandeep Mohindra1, Ravi Garg1, BD Radotra2
1 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||20-Aug-2014|
|Date of Decision||20-Aug-2014|
|Date of Acceptance||25-Sep-2014|
|Date of Web Publication||12-Nov-2014|
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Aggarwal A, Salunke P, Mohindra S, Garg R, Radotra B D. A case of cerebral pheohyphomycosis in an immunocompetent patient: Emphasis on intraoperative findings. Neurol India 2014;62:551-2
|How to cite this URL:|
Aggarwal A, Salunke P, Mohindra S, Garg R, Radotra B D. A case of cerebral pheohyphomycosis in an immunocompetent patient: Emphasis on intraoperative findings. Neurol India [serial online] 2014 [cited 2019 Sep 19];62:551-2. Available from: http://www.neurologyindia.com/text.asp?2014/62/5/551/144461
Cerebral pheohyphomycosis is a fungal infection caused by dematiaceous septate mycelial elements and is associated with a very high mortality unless diagnosed and treated early.  It is extremely difficult to diagnosis this fungal infection even with newer radiological modalities.
A 42-year-old male, cook by profession and apparently immunocompetent presented with headache and altered sensorium of 2 weeks duration. Examination was unremarkable except for bilateral mild papilledema. Magnetic resonance imaging (MRI) showed a T1-weighted hypointense lesion in right parietal region. The lesion was intensively contrast enhancing with multiple small lesions surrounding the main lesion [Figure 1]. It was hyperintense on T2-weighted sequence and there was restriction on diffusion-weighted imaging (DWI) [Figure 1]. In view of altered sensorium he was taken up for surgery with a preoperative diagnosis of high grade malignancy. During surgery, aspiration of the lesion showed pus. The abscess wall was removed in total after defining a clear plane of cleavage between brain and abscess. The wall of abscess had multiple blackish spots. The frozen section of abscess wall revealed granulomas and multinucleated giant cells containing pigmented fungi. Loading dose of amphotericin B was given intraoperatively. Biopsy report confirmed the diagnosis of fungal infection, pheohyphomycosis [Figure 2]. Patient has received 1,500 mg. of amphotericin B and is on oral voriconazole, doing well at follow-up.
|Figure 1: (a) NCCT head showing hypodense lesion in right parietooccipital region with surrounding perilesional edema. (b) MRI plain T1WI axial showing hypointense lesion and (c) ring enhancement on contrast. (d) MRI T2WI axial showing hyperintense lesion with perilesional edema. (e) MRI contrast T1WI sagittal showing ring enhancing lesion and a few satellite lesions. (f) MRI FLAIR coronal image showing almost isointense lesion with surrounding edema. (g) MRI DWI showing restriction of diffusion and (h) postoperative NCCT head showing complete excision of lesion. NCCT = Noncontrast computerized tomography, MRI = magnetic resonance imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging, FLAIR = fluid-attenuated inversion recovery, DWI = diffusion-weighted imaging|
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|Figure 2: (a) Microphotograph shows septate hyphae (curved arrow) engulfed by giant cells (straight arrow). The fungal elements are black in color. (a) Hematoxylin and eosin stain (×40) and (b) PAS stain ( ×40). PAS = Periodic acid-Schiff|
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The term pheohyphomycosis means dark pigmented fungal hyphae.  This infection is caused in majority of cases by a single order Chaetothyriales. About 50% patients of cerebral pheohyphomycosis are immunocompetent.  Various theories regarding the spread to brain have been proposed: Hematogenous dissemination, spread through lymphatic vessels, contiguous spread from adjacent organs such as orbits/sinuses.  Clinical presentation is like that of any other space occupying lesion with a shorter duration of symptoms than tumor. Classically described MRI findings are ring enhancing lesions on T1-weighted imaging, hypointensity of the rings on T2-weighted imaging, and low to high signal on DWI.  We were misled to the preoperative diagnosis of high-grade glioma in the present case because of absence of fever and other constitutional symptoms of infection and hyperintensity on T2-weighted imaging. Intraoperative frozen section is of paramount importance in such cases. This helps in instituting loading dose of antifungal intraoperatively. Any delay in starting antifungal therapy may affect the outcome.
The mortality of untreated cases of pheohyphomycosis is near 100% and with surgery and antifungal agents it is about 65%. , Because of this high mortality, a high index of suspicion is essential. Once suspected an urgent stereotactic guided aspiration of pus and fungal staining and culture should be the treatment option. In case the intraoperative findings raise the suspicion of fungal infection especially in the absence of typical clinicoradiological features, first dose of antifungal may be considered. A frozen section/crush smear done at the time of surgery immensely aids in diagnosis and management of cerebral fungal infections.
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[Figure 1], [Figure 2]