Favourable outcome of combined medical surgical treatment of cerebral aspergillosis of pulmonary origin

Sergio Ruiz-Santana,Cristóbal León-Gil,Carmen-Rosa Hernández-Socorro,Inmaculada Paz-Cruz,Jesús Cabrera-Arrocha,María-Isolina Campos-Herrero

doi:10.1099/jmmcr.0.005008

Abstract

Introduction: Cerebral aspergillosis is a highly fatal infection. Its origin is most likely blood-borne from the lungs and most patients are immunosuppressed. Mortality is over 90 % and the treatment chosen is key for survival. Case presentation: We report a 32-year-old female with a history of acute myeloid leukaemia (M3) who was admitted to the hospital due to a nodular infiltrate in the right superior lobe. A lung computed tomography (CT) scan displayed a right upper lobe cavitated nodule. A brain CT scan showed a right hemisphere deep abscess. Pulmonary aspergillosis was diagnosed after bronchoalveolar lavage. Three weeks later, while on antifungal treatment with voriconazole and liposomal amphotericin B, she suffered left motor focal deficits, and brain abscess puncture and aspiration by neuronavigation were performed for diagnosis and decompression. A PCR assay was positive for Aspergillus fumigatus. One week later, she developed an intraventricular brain haemorrhage requiring external ventricular drainage and intrathecal fibrinolysis with recombinant tissue plasminogen activator. She eventually achieved a good neurological outcome. A control brain CT showed an important reduction in mass size. Conclusion: Antifungal treatment is the mainstay for brain abscess treatment, and its combination with stereotactic needle aspiration is a better option compared with open surgery, particularly in abscesses located in deep motor areas.

Highlights

Cerebral aspergillosis is a highly fatal infection
Pathogenic mechanisms of infection are dependent on predisposing conditions
We present the case of a young woman with leukaemia and cerebral aspergillosis secondary to a primary lung infection with an excellent outcome, who received a combined medical and surgical treatment

Summary

Introduction

Central nervous system aspergillosis is a highly fatal infection and the lung is usually its primary focus (Brouwer et al, 2014; Kourkoumpetis et al, 2012; Marr et al, 2015; Spapen et al, 2014). Three weeks after ICU admission and while on antifungal treatment, the patient suddenly suffered left motor focal deficits, and brain abscess puncture and aspiration by neuronavigation were performed for diagnosis and decompression (Brouwer et al, 2014). Combined surgical treatment of cerebral aspergillosis with two antifungals, each with a target effect on the two affected organs: liposomal amphotericin B for the lungs and voriconazole for the brain. Invasive cerebral aspergillosis is the most lethal manifestation of invasive Aspergillus infection and has historically been associated with a mortality rate close to 90 %, regardless of the immune status of the patient This serious prognosis highlights the outstanding outcome of a combined medical and surgical treatment approach in our patient

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