Central Nervous System Aspergillosis

Abstract

Central nervous system (CNS) aspergillosis is a highly fatal infection. We review the clinical presentation, diagnosis, and outcome of this infection and present a case series of 14 consecutive patients with CNS aspergillosis admitted to Massachusetts General Hospital (MGH) from 2000 to 2011. We also review 123 cases reported in the literature during that time. We included only proven CNS aspergillosis cases conforming to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal infections. In the MGH case series, neutropenia, hematologic malignancies, autoimmune diseases requiring steroid treatment, and solid organ transplantation were the predominant comorbid conditions. Notably, all MGH patients were immunosuppressed, and more than half (n = 8) had a history of previous brain injury, unrelated to their index hospitalization. For most MGH patients (11 of 14), the lung was the primary focus of aspergillosis, while 2 had paranasal sinus involvement, and 1 had primary Aspergillus discitis. Among reported cases, paranasal sinuses (27.6%) and the lung (26.8%) were the primary foci of infection, whereas 22% of those cases had no obvious primary organ involvement. Although a selection bias should be considered, especially among published cases, our findings suggest that patients who underwent neurosurgery had improved survival, with MGH and literature patients having 25% and 28.6% mortality, respectively, compared to 100% and 60.4%, respectively, among patients who received only medical treatment. Although this was not the case among MGH patients, CNS aspergillosis can affect patients without significant immune suppression, as indicated by the high number of reported immunocompetent cases. In conclusion, mortality among CNS aspergillosis patients remains high, and the infection may be more common among patients with previous brain pathology. When indicated, neurosurgical procedures may improve prognosis.

Necrotizing Liver Granuloma/Abscess and Constrictive Aspergillosis Pericarditis with Central Nervous System Involvement: Different Remarkable Phenotypes in Different Chronic Granulomatous Disease Genotypes

“…In more than 50% of cases, lungs or paranasal sinuses are primary foci of infection [24]. Hematogenous dissemination from lungs can cause meningitis, abscess formation, or vascular pathology in the form of thrombosis and infarction [25].…”

“…Patients may present with seizures, headaches, fever, focal neurological signs per the pathology, and localization [14, 25]. Radiologically edema, hemorrhage, and ring enhancement are cardinal findings and nonspecific hyperintense foci are also defined [19, 24, 25]. …”

“…Amphotericin B and voriconazole both penetrating blood-brain-barrier were mostly used in combination with other antifungals in literature. Surgery is a treatment choice improving survival in patients with abscesses but was not necessary in our case [15, 24–26]. After two months of parenteral antifungal treatment, oral voriconazole was planned to be continued for at least 12–18 months for this patient.…”

Diagnostic Performance of Galactomannan Antigen Testing in Cerebrospinal Fluid

“…The diagnosis is challenging, as radiological findings are nonspecific and cerebrospinal fluid (CSF) cultures are positive only in less than one-third of cases (3,4). Moreover, obtaining brain tissue for histopathological examination, the diagnostic gold standard, is frequently not feasible.…”

Mold Infections of the Central Nervous System

“…19 Meningeal signs are uncommon, and their presence is indicative of a subarachnoid hemorrhage. 20 CNS aspergillosis should be high on the list of disorders in the differential diagnosis for patients with immunosuppression and focal brain lesions, especially those with characteristic pulmonary infiltrates in whom focal neurologic deficits or focal seizures develop.…”