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EXPERT COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 15-16

His Master's Voice Expert Commentary on Pearls from Past


Department of Neurosurgery, AIIMS, New Delhi; National Brain Research Center (NBRC), Delhi, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Prof. P N Tandon
Emeritus Professor, Department of Neurosurgery, AIIMS, New Delhi; President, National Brain Research Center (NBRC), 1, Jagrit Enclave, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279668

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How to cite this article:
Tandon P N. His Master's Voice Expert Commentary on Pearls from Past. Neurol India 2020;68:15-6

How to cite this URL:
Tandon P N. His Master's Voice Expert Commentary on Pearls from Past. Neurol India [serial online] 2020 [cited 2020 Jul 3];68:15-6. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/15/279668







  Cerebral Chromoblastomycosis Top


This is the first part of the landmark article published by Prof Dastur in 1966.[1] It becomes relevant today as the fungal infections of the CNS have seen a steep rise in the past decades because of increase in conditions such as AIDS, rampant usage of steroids and high dosage long term antibiotics and immunosuppressive drugs for a variety of conditions. The authors describe here a rare case of fungal infection of the brain caused by Cladosporium bantianum species. This fungus has been the subject of significant taxonomical confusion and recently been classified under the genus Cladophialophora. These fungi are a common cause of skin infection in humans and hence called as dematiaceous fungi. C bantiana is the most common skin fungus having neurotropism and causing cladiosporiosis. The incidence has been increasing lately. There are two types of infection- disseminated systemic phaeohyphomycosis (DSP) associated with immunodeficiency and cerebral phaeohyphomycosis.[2],[3] Their outcomes are poor with survival rates ranging from 30-45% and this can be attributed to delay in diagnosis.

The accepted mode of infection is by inhalation and involvement of the lungs and subsequent hematogenous spread to the brain. The most common CNS involvement is brain abscess; others being, meningitis or meningo encephalitis.[4]

There are no specific clinical and radiological features to support the diagnosis. The clinical features depend upon the location of the involvement and range from hemiparesis, seizures, fever and signs of raised intracranial pressure.

The lumbar puncture shows evidence of pleocytosis, polymorphonuclear cell predominance in with most of the patients. However, CSF is sterile in most of the patients. The diagnosis is made by the morphological identification of the fungus in human brain tissue after the surgery or at autopsy.[5]

While the air ventriculogram was used for supportive diagnosis, when Prof. Dastur published this paper, the CT/MRI of the brain with contrast is the mainstay of diagnosis in recent times. It shows the presence of an abscess, which is not possible to differentiate from a bacterial or tubercular abscess. However, occasionally the edema surrounding the lesion may be disproportionate.[6] Surgical treatment depends on the pathomorphology of the disease. The surgical options include- biopsy and aspiration, burr hole and tapping and craniotomy and excision of abscess (which is a better surgical treatment as compared to the rest). The fungal pus may also be difficult to tap and hence might require multiple attempts sometimes, and antifungals are more effective after the definitive excision of brain abscess.[2],[5],[7]

The medical treatment has significantly evolved over the last six decades with the advent of antifungal therapy: Amphotericin B, Itraconazole, flucytosine, and newer triazoles such as voriconazole and Posaconazole. Amphotericin B alone has limited efficacy and the combination therapy is more effective.[3],[7] However, even with the advances in medical and surgical treatment, the overall outcome remains dismal with high mortality rates.



 
  References Top

1.
Dastur HM, Chaukar AP, Rebello MD. Cerebral Chromoblastomycosis due to Cladosporium Trichoides (Bantianum) - Part I. Neurol India 1966;14(3):1-5.  Back to cited text no. 1
    
2.
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. 2
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3.
Chakrabarti A, Kaur H, Rudramurthy SM, Appannanavar SB, Patel A, Mukherjee KK, Ghosh A, Ray U. Brain abscess due to Cladophialophora bantiana: A review of 124 cases. Med Mycol 2016;54:111-9.  Back to cited text no. 3
    
4.
Shankar SK, Mahadevan A, Sundaram C, Sarkar C, Chacko G, Lanjewar DN, et al. Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario. Neurol India 2007;55:198-215.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Garzoni C, Markham L, Bijlenga P, Garbino J. Cladophialophora bantiana: A rare cause of fungal brain abscess. Clinical aspects and new therapeutic options. Med Mycol 2008;46:481-6.  Back to cited text no. 5
    
6.
Jain KK, Mittal SK, Kumar S, Gupta RK. Imaging features of central nervous system fungal infections. Neurol India 2007;55:241-50.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
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.  Back to cited text no. 7
[PUBMED]  [Full text]  




 

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