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Table of Contents    
LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 1062-1064

Is complete excision the key to cure for Cladophialophora bantiana brain abscess? A review of literature


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Ramesh S Doddamani
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190250

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How to cite this article:
Dash C, Kumar A, Doddamani RS. Is complete excision the key to cure for Cladophialophora bantiana brain abscess? A review of literature. Neurol India 2016;64:1062-4

How to cite this URL:
Dash C, Kumar A, Doddamani RS. Is complete excision the key to cure for Cladophialophora bantiana brain abscess? A review of literature. Neurol India [serial online] 2016 [cited 2019 Nov 13];64:1062-4. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/1062/190250




Sir,

Cladophialophora bantiana is a melanized mycelial fungus and accounts for almost 50% of the brain abscesses caused by melanized fungi.[1] It occurs in both immunocompetent and immunocompromised individuals and is associated with a high mortality of up to 70%.[2] We report a case of C. bantiana brain abscess in an immunocompetent individual. The abscess required resurgery for the residual abscess and progressed in spite of antifungal therapy.

A 50-year-old male patient presented with chief complaints of headache with progressive left-sided weakness for 3 months and altered sensorium for 7 days. On examination, the patient was hemiplegic on the right side. The patient was diagnosed as a case of tuberculous brain abscess at a peripheral center based on the imaging findings and was started on antituberculous drugs, steroids, decongestants, and phenytoin. There was no history of diabetes mellitus, organ transplantation or steroid intake prior to the diagnosis of the lesion nor was there any history of significant weight loss, prolonged fever, or previous history of tuberculosis. The patient was intubated in the emergency room in view of his poor Glasgow coma scale score (E2VintubatedM5). Imaging of the brain revealed multiple lesions in the right frontal and parietal lobes, hypointense on T1 weighted images (WI), hyperintense on T2WI with a hypointense rim, and ring enhancement on post-gadolinium images, with extensive perilesional edema and midline shift [Figure 1]. The patient was taken up for emergency surgery. A right frontoparietal craniotomy was done. An intraoperative diagnosis of abscess was made as approximately 30 ml of pus was drained from the abscess and the three abscess cavities were excised. The patient's sensorium and power on the right side (grade: 2/5) improved during the postoperative period. The postoperative scan revealed residual abscess in the vicinity of the precentral gyrus with perilesional edema. His histopathology was compatible with phaeohyphomycosis as there were multiple epitheloid cell granulomas with numerous foreign body giant cells containing yeast forms and a few hyphal forms of pigmented fungi. The fungal culture revealed C. bantiana. However, susceptibility testing was not available. The patient was started on liposomal amphotericin B (AmB) at 5 mg/kg/day on the first postoperative day based upon a provisional diagnosis of fungal abscess. Voriconazole 200 mg bd per oral was added to AmB when the culture report and definitive histopathological diagnosis was available. The residual abscess was observed for 4 weeks with serial imaging performed once weekly because the patient was unwilling for the second surgery. As there was no decrease in the abscess size with persisting perilesional edema on serial imaging [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d and [Figure 3]a,[Figure 3]b, the patient was convinced to undergo a repeat surgery and the abscess was excised completely [Figure 3]c using peroperative ultrasound guidance and electrophysiological monitoring. The patient's power gradually improved following his second surgery to grade 4/5 on the right side. Liposomal AmB was withheld after a cumulative dose of 7 g due to deranged renal profile, and the patient was discharged on oral voriconazole at 200 mg bd. The patient is doing well at 3 months with no evidence of recurrence [Figure 3]d and [Figure 3]e.
Figure 1: (a) Contrast enhanced magnetic resonance imaging (CEMRI) brain axial section showing multiple ring enhancing lesions in the right frontal and parietal lobes, with mass effect and midline shift. (b) T2 weighted image (T2WI) axial section showing multiple lesions with a hyperintense center surrounded by a hypointense rim. (c) Contrast enhanced computed tomography head showing multiple ring enhancing lesions in the right frontal and parietal lobes with mass effect and midline shift

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Figure 2: (a) Magnetic resonance imaging T2 weighted image, axial section done 1 month after the first surgery showing a residual abscess with a hyperintense core surrounded by a hypointense rim and extensive perilesional edema, with persistent postoperative changes. (b and c) Contrast enhanced magnetic resonance imaging, axial section done at the same time showing a ring enhancing residual lesion with enhancement along the previous operative site tract. (d) Magnetic resonance spectroscopy showing the lipid peak (the patient was on liposomal amphotericin B and voriconazole)

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Figure 3: (a and b) Contrast enhanced computed tomography (CECT) head done after 37 days and 44 days respectively showing the residual abscess and persistent perilesional edema in spite of antifungals and decongestants. (c) CECT head following excision of the residual abscess. (d) Contrast enhanced magnetic resonance imaging brain at 3 months showing no residual abscess with existence of postoperative changes. (e) T2 weighted image axial section at 3 months showing postoperative changes with significant resolution of the perilesional edema and mass effect (the patient was on tablet voriconazole)

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C. bantiana is a highly neurotropic fungi causing brain abscess in both immunocompromised and immunocompetent individuals, with most of the cases being reported from Asian countries, especially from India.[3] The frontal lobe followed by the parietal lobe are the most common sites of the abscess and lead us to believe that the agent possibly enters the brain through bloodstream from remote inoculation sites such as the lungs or subcutaneous nodules.[3] A few authors recommend burr hole tapping/stereotactic biopsy followed by antifungal treatment as the initial treatment modality in such abscesses.[3],[4] The antifungal regimen for these abscesses does not have a consensus protocol as yet, with patients being treated with AmB and flucytosine initially, with itraconazole, voriconazole, and posaconazole also being used with liposomal AmB.[4],[5] ESCMID (European Society of Clinical Microbiology and Infectious Diseases) and ECMM (European Confederation of Medical Mycology) joint clinical guidelines recommend a regimen of combination antifungal medication for fungal cerebral abscesses when surgery is not possible due to dissemination of the abscess throughout the brain or in patients with an immunocompromised status/poor general condition.[6] This paper highlights a few important findings: (1) A differential diagnosis of intraparenchymal fungal abscess should be considered even in immunocompetent individuals with ring enhancing lesions. (2) Complete surgical excision may be the key to cure such cases, as shown in our patient in whom the lesion and edema persisted despite administration of a combination antifungal therapy in appropriate dose. (3) Liposomal AmB and voriconazole may be given in combination in such cases with a good response.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Revankar SG, Sutton DA, Rinaldi MG. Primary central nervous system phaeohyphomycosis: A review of 101 cases. Clin Infect Dis 2004;38:206-16.  Back to cited text no. 1
[PUBMED]    
2.
Kantarcioglu AS, de Hoog GS. Infections of the central nervous system by melanized fungi: A review of cases presented between 1999 and 2004. Mycoses 2004;47:4-13.  Back to cited text no. 2
[PUBMED]    
3.
Garg N, Devi IB, Vajramani GV, Nagarathna S, Sampath S, Chandramouli BA, et al. Central nervous system cladosporiosis: An account of ten culture-proven cases. Neurol India 2007;55:282-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Lyons MK, Blair JE, Leslie KO. Successful treatment with voriconazole of fungal cerebral abscess due to Cladophialophora bantiana. Clin Neurol Neurosurg 2005;107:532-4.  Back to cited text no. 4
[PUBMED]    
5.
Al-Abdely HM, Najvar LK, Bocanegra R, Graybill JR. Antifungal therapy of experimental cerebral phaeohyphomycosis due to Cladophialophora bantiana. Antimicrob Agents Chemother 2005;49:1701-7.  Back to cited text no. 5
[PUBMED]    
6.
Chowdhary A, Meis JF, Guarro J, de Hoog GS, Kathuria S, Arendrup MC, et al. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: Diseases caused by black fungi. Clin Microbiol Infect 2014;20(Suppl 3):47-75.  Back to cited text no. 6
[PUBMED]    


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