Central nervous system Aspergillus infection after epidural analgesia: diagnosis, therapeutic challenges, and literature review

Abstract

Aspergillus terreus was identified in an intra-dural spinal biopsy specimen from an African female with recurrent headache and hydrocephalus. Prior laboratory testing of cerebrospinal fluid (CSF) was non-diagnostic, despite extensive central nervous system (CNS) involvement. CNS Aspergillus infection presents a diagnostic and therapeutic challenge and is reviewed in the context of this particularly instructive and difficult case. CASE PRESENTATION AND DISCUSSIONThe patient was a 37 year old West African female who presented to our emergency department with headache, blurry vision, and numbness in the left lower extremity. Twelve months prior to admission, while still living in Africa, she underwent a cesarean section accompanied by epidural analgesia. Her post-partum course was notable for episodes of recurrent headache. She subsequently moved to the United States where her headaches continued.The patient returned to Africa three months prior to the present admission. During that time she visited an emergency department with symptoms of severe headache, and a computed tomography (CT) scan demonstrated dilation of the lateral, third, and fourth cerebral ventricles. She returned to the United States and presented to our emergency department shortly thereafter.The patient had an admission temperature of 37.4°C. Bilateral papilledema, mild oral thrush, and brisk deep tendon reflexes in the lower extremities were noted on physical examination. Brain magnetic resonance imaging (MRI) suggested communicating hydrocephalus ( Figure 1A), although slight abnormal enhancement anterior to the pons and encasing the basilar artery was also noted (not shown).Initial complete blood count (CBC), erythrocyte sedimentation rate (ESR), and serum chemistries were in the normal range. A lumbar puncture on Day 1 (Table 1) Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Numerous tests for human immunodeficiency virus (HIV) and hepatitis A, B, and C were all negative. Serum angiotensin converting enzyme and calcium were both normal, and tuberculin skin testing was negative. A repeat lumbar puncture (Day 5) showed persistent hypercellularity but was read as negative for malignant cells by cytology. Cell counts, chemistries, and smears/ cultures were otherwise unchanged. NIH Public AccessUpon consultation with the neurosurgical team and consent of the patient, a ventriculoperitoneal (VP) shunt was placed on Day 7, although she declined a surgical biopsy of the area of abnormal brain MRI enhancement. Placement of the shunt was accompanied by significant symptomatic improvement. An MRI of th...

Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient

“…5 Voriconazole has proven to be significantly superior to conventional amphotericin B, and has led to a profound survival improvement in patients with CNS aspergillosis. 2,6 Combination therapies with two antifungal compounds are the common treatment protocol. Although the surgical treatment of Aspergillus infection is still controversial, our experience is that surgery combined with antifungal therapy may improve survival.…”

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

“…For diagnosis of cerebral aspergillosis the value of neuroimaging and also non‐culture‐based methods (e.g. PCR, biomarkers) cannot be overstated, since sensitivity of culture may be below 50% . In cerebral aspergillosis, either stereotactic or open craniectomy for biopsy, abscess drainage or excision of lesions is recommended to prevent serious neurological sequelae and improve outcome and survival .…”

“…Overall, neurosurgical interventions for establishing the diagnosis of CNS aspergillosis is strongly encouraged as other fungal pathogens may cause similar disease manifestations . Surgical drainage in case of progression under systemic antifungal therapy is also recommended in patients with epidural aspergillosis to prevent serious neurological sequelae and improve outcome …”

“…PCR, biomarkers) cannot be overstated, since sensitivity of culture may be below 50%. 15 In cerebral aspergillosis, either stereotactic or open craniectomy for biopsy, abscess drainage or excision of lesions is recommended to prevent serious neurological sequelae and improve outcome and survival. [16][17][18][19][20] In cerebral mould infection, the surgical approach is also of great importance for diagnostic purposes, which may have therapeutic implications since the pharmaceutical treatment can be limited due to the inability of some antifungal drugs to cross the blood-brain barrier.…”

Intracranial Aspergillosis Mimicking a Middle Cranial Fossa Tumor Involving the Cavernous Sinus in an Immunocompetent Patient: Case Report and Literature Review

“…Acording to Panda et al, the combination of these antifungal drugs for skull base aspergillosis may be effective [17], with low risk. Intracranial aspergillosis has often a bad outcome with high mortality [13]. However, prognosis seems to be better in craniocerebral Aspergillosis of sinonasal [4,24].…”