Fungal mycotic aneurysm in a patient withAspergillus terreuschronic meningoencephalitis

Abstract

Background: Central nervous system involvement due to aspergillosis is an extremely serious entity, particularly in patients with severe neutropenia, hematological diseases, or post-transplant cases. Immunocompetent patients can be infected by intense exposure, particularly iatrogenic after invasive procedures. Case Description: We present the case of a 26-year-old male with a 1 year appendectomy background, which required epidural anesthesia. After that surgery, insidious headache presented, requiring mild analgesics for adequate control. In the following weeks, headaches increased and tomographic imaging revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and empirical treatment for neurocysticercosis was established, but diagnosis was never confirmed. Sequentially, shunt dysfunction occurred twice, for which shunt replacement was performed. Cerebrospinal fluid and shunt’s catheter were cultured. Some days later, a filamentous fungus was isolated and finally identified as Aspergillus sp. Intravenous amphotericin B and fluconazole at therapeutic dosage were administered; however, a torpid clinical evolution was observed. After a 2-week antifungal scheme, the fungus was identified as Aspergillus terreus. The patient developed sudden rostrocaudal deterioration. Computed tomography imaging was done, revealing a 70 cc hematoma in the right operculoinsular region, midline shift, and a 9 mm saccular aneurysm at the bifurcation of the middle cerebral artery. Conclusion: Cerebral aspergillosis is a serious disease with high mortality in patients, particularly those without identifiable risk factors. The iatrogenic forms are serious, due to the delay of clinical diagnosis. It is important to have a high index of suspicion in patients with a history of invasive procedures such as epidural anesthesia or surgery, and who develop a persistent chronic headache or chronic meningitis.

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review

“…e involvement of a large amount of liquor and the performance of repeated microbiological studies can provide the possibility of the infectious agent identification. [8] Alternative "non-culture-based" methods of verification of the infectious agent have higher sensitivity and specificity. ey include galactomannan test that detects the antigens to the fungal cell walls and is widely used for the diagnostic of invasive aspergillosis and monitoring of the effectiveness of pharmacotherapy.…”

“…According to the published data, around 60% of patients with histologically verified aspergillosis have a clinical trial of a mycotic aneurysm, cerebral infarction, and multiple infectious granulomas. [ 2 , 8 , 13 ] The production of elastase by the fungi contributes to the destruction of elastin and invasion to the arterial wall. Such focal inflammatory response can lead to the formation of an aneurysm, its rupture, and the development of subarachnoid hemorrhage.…”

“…The involvement of a large amount of liquor and the performance of repeated microbiological studies can provide the possibility of the infectious agent identification. [ 8 ]…”

“…Sangrador-Deitos et al . [ 8 ] described a clinical case of CNS aspergillosis in a patient with hydrocephaly after ventriculoperitoneal shunting. The shunt was removed because of its failure.…”

“…as a causative agent can be made only retrospectively after the patient’s death, which highlights diagnostic difficulties associated with this condition. [ 8 ] It should be mentioned that early diagnostic of aspergillosis leads to an increase in the overall survival rate. We presented a clinical case of a 58-year-old man who developed an Aspergillus abscess in the chiasmosellar region and an associated mycotic aneurysm of the right middle cerebral artery (MCA) and intracerebral hemorrhage.…”