CNS aspergillosis in a patient with Crohn's disease on immunosuppressants: a case report

Shreyansh Shah; Peyman Shirani; Heike Schmolck; William C Young; Paul E Schulz

doi:10.4076/1757-1626-2-6376

Case Report
Open Access

CNS aspergillosis in a patient with Crohn's disease on immunosuppressants: a case report

Shreyansh Shah¹,
Peyman Shirani²,
Heike Schmolck³,
William C Young³ and
Paul E Schulz²Email author

Cases Journal20092:6376

https://doi.org/10.4076/1757-1626-2-6376

Received: 4 March 2009

Accepted: 22 April 2009

Published: 16 June 2009

Abstract

Fungal infections of the central nervous system are an uncommon cause of rapid decline in consciousness. We describe the case of central nervous system aspergillosis in a patient on immunosupressants whose clinical course highlights the need for an aggressive approach to diagnosis.

Keywords

Aspergillosis
Antifungal Therapy
Immunocompromised Host
Mycotic Aneurysm
Deep White Matter

Case presentation

A 53-year-old right-handed Caucasian woman with a history of Crohn's disease for four decades presented with pneumonia and a change in mental status. She was taking prednisone daily for a recent Crohn's exacerbation. Methotrexate was added 2 weeks prior. On physical examination, she had hypotension, tachycardia and thrombocytopenia. She was comatose and responses to painful stimuli were decreased on left side. A CT scan of the brain showed multiple areas of hypodensity. A brain MRI (Figure 1) showed numerous foci of T1 hypointensity and T2 hyperintensity in the periventricular, subcortical and deep white matter, including the gray-white junction. There were also lesions in the basal ganglia, thalami, pons and cerebellum that showed diffusion restriction. The distribution and properties of these radiological images were suggestive of septic emboli. She had an extensive left upper lobe consolidation on chest X-Ray. Bronchoscopy revealed aspergillus, which lead to a diagnosis of CNS aspergillosis. Despite antifungal therapy she succumbed to her disease and the decision was made to withdraw care in light of her poor neurological status.

Figure 1
**Axial MR images demonstrating diffusion restriction (A & B), hyperintensities on FLAIR images (C), and hypointensities on T1 images (D)**.

Discussion

Aspergillus is a saprophytic, opportunistic fungus that can infect humans, especially immunocompromised hosts [1]. The primary portal of entry for aspergillus is the respiratory tract. From there, it secondarily infects the brain via hematogenous spread. In some cases, it can also result from penetrating trauma or extension of infection from the mastoid air sinuses [2].

CNS aspergillosis should be considered in patients presenting with the acute onset of focal neurologic deficits, especially in immunocompromised hosts. The most frequent symptoms are headache, vomiting, convulsion, hemiparesis, fever, cranial nerve deficits, paralysis and sensory impairment of varying degrees. Since aspergillus can form mycotic aneurysms, it can lead to subarachnoid hemorrhage and meningeal signs. The propensity of the fungus to invade blood vessels may lead to extensive necrosis or intracranial bleeding [3].

The MRI in CNS aspergillosis typically shows infarction or abscesses in multiple brain areas, including the basal ganglia and thalami [4]. Although the mortality rate in CNS aspergillosis approaches 95% [5], recent reports suggest that early initiation of antifungal therapy with neurosurgical intervention can improve outcomes [6].

Consent

Written informed consent was obtained from the patient's family for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

List of abbreviations

CT:: Computerized tomography

CNS:: Central nervous system

MRI:: Magnetic resonance imaging.

Declarations

Authors’ Affiliations

(1)

Department of Neurobiology and Anatomy, University of Texas Health Science Center at Houston, Houston, USA

(2)

Department of Neurology, NB-302, Baylor College of Medicine, One Baylor Plaza, Houston, USA

(3)

Mercy Ruan Neurology Clinic, Des Moines, USA

References

Nadkarni T, Goel A: Aspergilloma of the brain: an overview. J Postgrad Med. 2005, 51: S37-S41.PubMedGoogle Scholar
Marinovic T, Skrlin J, Vilendecic M, Rotim K, Grahovac G: Multiple aspergillus brain abscesses in immuno-competent patient with sever cranio-facial trauma. Acta Neurochir (Wien). 2007, 149: 629-632. 10.1007/s00701-007-1148-7.View ArticleGoogle Scholar
Sharma RR, Lad SD, Desai AP, Lynch PG: Operative Neurosurgical Techniques: Indications, Methods and Results. Edited by: SchmidekSweet. 2000, Saunders Company, 1726-1755. 4Google Scholar
DeLone DR, Goldstein RA, Petermann G, Salamat MS, Miles JM, Knechtle SJ, et al: Disseminated aspergillosis involving the brain: distribution and imaging characteristics. Am J Neuroradiol. 1999, 20: 1597-1604.PubMedGoogle Scholar
Patterson TF: Principles and Practice of Infectious Diseases. Edited by: Mandell GLBennett JEDolin R. 2005, Churchill Livingstone, 2958-2972. 6Google Scholar
Schwartz S, Ruhnke M, Ribaud P, Corey L, Driscoll T, Cornely OA, et al: Improved outcome in central nervous system aspergillosis using voriconazole treatment. Blood. 2005, 106: 2641-2645. 10.1182/blood-2005-02-0733.View ArticlePubMedGoogle Scholar

Copyright

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.