Abstract
BACKGROUNDCladophialophora bantiana is a dematiaceous, saprophytic fungus and a rare but reported cause of intracranial abscesses due to its strong neurotropism. Although it predominantly affects immunocompetent individuals with environmental exposure, more recently, its significance as a highly lethal opportunistic infection in transplant recipients has been recognized. Successful treatment requires timely but often challenging diagnosis, followed by complete surgical excision. Next-generation sequencing of microbial cell-free DNA (cfDNA) from plasma is a novel diagnostic method with the potential to identify invasive fungal infections more rapidly and less invasively than conventional microbiological testing, including brain biopsy.OBSERVATIONSThe authors described the case of a recipient of a liver transplant who presented with seizures and was found to have innumerable ring-enhancing intracranial lesions. The Karius Test, a commercially available method of next-generation sequencing of cfDNA, was used to determine the causative organism. Samples from the patient’s plasma identified C. bantiana 6 days before culture results of the surgical specimen, allowing optimization of the empirical antifungal regimen, which led to a reduction in the size of the abscesses.LESSONSThe authors’ findings suggest that microbial cfDNA sequencing may be particularly impactful in improving the management of brain abscesses in which the differential diagnosis is wide because of immunosuppression.
Highlights
Cladophialophora bantiana is a dematiaceous, saprophytic fungus and a rare but reported cause of intracranial abscesses due to its strong neurotropism
Brain magnetic resonance imaging (MRI) on day showed stability of the abscesses and improved vasogenic edema (Fig. 1A, right), but his overall condition deteriorated because of worsening renal failure and thrombocytopenia, causing an acute hemorrhage into the abscess resection cavity on day. He was transitioned to palliative care and expired on day 29. Observations This is the first reported case illustrating the use of plasma microbial cell-free DNA (cfDNA) sequencing to diagnose cerebral abscesses due to C. bantiana, and only the second, to our knowledge, to demonstrate liquid biopsy detection of the causative organism of an isolated intracranial abscess of any etiology.[8]
Complete surgical excision is the only identified independent predictor of survival,[2] but this aggressive approach differs from that taken in most patients presenting with brain abscesses, in whom stereotactic needle aspiration is generally favored over excision as the initial procedure.[11]
Summary
Cladophialophora bantiana is a dematiaceous, saprophytic fungus and a rare but reported cause of intracranial abscesses due to its strong neurotropism. Cladophialophora bantiana is a ubiquitous dematiaceous, saprophytic fungus commonly found in soil.[1] Highly neurotropic, C. bantiana is a rare but recognized cause of intracranial abscess, with just 32 cases reported in North America between 1952 and 2014, mostly in immunocompetent male patients.[2,3] In immunocompromised patients, recipients of solid organ transplant, C. bantiana brain infections have been increasingly reported[4,5] and may have a mortality rate as high as 80% because of poor responses to empirical antifungal monotherapy, the presence of multiple abscesses, and delays in establishing the diagnosis, which generally requires brain biopsy. Unauthenticated | Downloaded 02/17/22 09:42 AM UTC practice, given its lower specificity compared to conventional diagnostics.[9,10] Here, we describe a case of multiple intracranial C. bantiana abscesses in a recipient of a liver transplant in whom Karius testing revealed the diagnosis prior to brain biopsy results and discuss its potential use in rare, invasive fungal infections of the central nervous system
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