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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 22  |  Issue : 1  |  Page : 52-55

Hemispheric multiple fungal brain abscesses due to Scedosporium apiospermum following surgery


1 Department of Radiology, Vikram Hospitals, Bangalore, Karnataka, India
2 Department of Neurosciences, Vikram Hospitals, Bangalore, Karnataka, India
3 Department of Microbiology, Vikram Hospitals, Bangalore, Karnataka, India

Date of Web Publication3-Dec-2014

Correspondence Address:
Dr. Ravindra B Kamble
Department of Radiology, Vikram Hospitals, Millers Road, Bangalore - 560 052, Karnataka
India
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DOI: 10.4103/1115-1474.146156

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  Abstract 

We report an interesting and rare case of hemispheric multiple brain abscesses due to Scedosporium apiospermum which developed following neurosurgery and mimicked hemiconvulsion hemiplegia epilepsy syndrome on initial scans. Interestingly all the abscesses were only on the right side of cerebral hemisphere which later on spread to the other side. All the lesions had hemorrhagic walls seen as hypointensities on susceptibility weighted imaging. The patient succumbed to this fatal fungal brain infection.

Keywords: Brain; fungal abscess; magnetic resonance imaging; Scedosporium apiospermum


How to cite this article:
Kamble RB, Rao RM, Raghavendra S, Athmanathan S. Hemispheric multiple fungal brain abscesses due to Scedosporium apiospermum following surgery. West Afr J Radiol 2015;22:52-5

How to cite this URL:
Kamble RB, Rao RM, Raghavendra S, Athmanathan S. Hemispheric multiple fungal brain abscesses due to Scedosporium apiospermum following surgery. West Afr J Radiol [serial online] 2015 [cited 2022 Jan 22];22:52-5. Available from: https://www.wajradiology.org/text.asp?2015/22/1/52/146156


  Introduction Top


Scedosporium apiospermum is a filamentous fungus and is an asexual form of the fungus Pseudallescheria boydii. It is an ubiquitous saprophytic fungus found in the soil, manure, decaying vegetation, polluted swimming pools and streams. [1] Central nervous system involvement by the fungus is often fatal and commonly causes abscess, meningitis, ventriculitis and vascular invasion leading to infarction. [2] We report a rare case of multiple brain abscesses due to S. apiospermum developed after surgery. Initially all the brain abscesses were located on the right side of the cerebrum but later spread to the opposite hemisphere. All the fungal abscesses had hemorrhagic walls confirmed on surgery and histopathology.


  Case Report Top


A 9-year-old boy presented to our hospital with 5 day history of unsteady gait, headache and vomiting. On examination he had horizontal nystagmus and grade 4/5 power in the left hand. Imaging done in other hospital showed trapped fourth ventricle with dilated left occipital horn due to loculations (not shown). All laboratory investigations were within normal. In the past, the patient had neonatal pseudomonas meningitis and staphylococcal osteomyelitis of left humerus. Later the patient had hydrocephalus for which ventriculo-peritoneal (VP) shunt was done. This required repeated shunt revisions due to malfunctions. Again the patient presented with features of raised intracranial pressure. The patient also underwent endoscopic fenestration of left occipital horn and fourth ventricular loculations. After 3 hours of surgery he developed high grade fever with two episodes of left focal seizures and left-sided hemiparesis. Immediate computed tomography (CT) scan (Siemens somatom sensation 64 slice) was done which showed post operative changes, shunt tubes and gliosis in the left frontal lobe [Figure 1]. Hemiplegia persisted even on next day. Repeat CT scan showed diffuse right hemispheric hypodensity probably suggestive of hemiconvulsion hemiplegia epilepsy syndrome [Figure 2]. The patient continued to deteriorate, so magnetic resonance imaging (MRI) (Siemens Avanto Numaris Syngo, Germany) was done on the fourth day with T1W (TR-603, TE-17, ET-1), T2W (TR-5210, TE-116, ET-15), FLAIR (TR-9290, TE-92, ET-16), 3D susceptibility weighted gradient sequence (TR-49 and TE-40), diffusion (TR- 3728, TE-102, NEX-4, bandwidth 964) sequences and contrast (Multiphance (gadobenate dimeglumine) Bracco Milano Italy). Imaging showed right cerebral hemispheric hyperintensity on T2W with restricted diffusion and multiple ring enhancing lesions with meningeal enhancement [Figure 3]. Possibility of brain abscesses was considered and the patient was treated with higher antibiotics. Echo was done which was normal. CSF analysis showed no growth and cell count of 89 cell/cumm, sugar 52 mg/dl, protein 84 mg/dl, and chloride 130 mmol/l. Repeat MRIs showed worsening state with increase in size and number of lesions. Susceptibility weighted imaging showed a blooming effect in the wall of ring enhancement [Figure 4]. The patient continued to deteriorate with increase in mass effect. Right temporal lobectomy and decompressive surgery were done. Histopathology revealed dense hemorrhagic cerebritis with necrosis, inflammation and vascular thrombosis and detectable short fungal hyphae in the vessels and necrotic tissue. Culture showed it to be S. apiospermum.
Figure 1: (a-d) CT scan images in A (axial) and B (reconstructed sagittal) showing postoperative findings as air in fenestrated trapped fourth ventricle with shunt tube. Image C showing old gliotic changes in right frontal lobe and endoscopic operative tract (hyperdense bleed) in left frontal lobe. Image D showing no obvious brain edema

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Figure 2: (a-c) CT scan axial images showing hemispheric edema seen as hypodensity on the right side in A, B and C images with air in trapped 4th ventricle in A and shunt tube in B

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Figure 3: (a-d) FLAIR axial images in A showing right cerebral hemispheric hyperintensity with small scattered nodular hypointense lesions. T2W axial images in B showing right cerebral hemispheric hyperintensity with small nodular lesions with hyperintense periphery and hypointense center. Post contrast T1W axial images in C showing multiple ring enhancing lesions all scattered only on the right side of cerebral hemisphere with meningeal enhancement. Diffusion images in D showing restricted diffusion in right cerebral hemisphere

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Figure 4: (a-c) FLAIR axial images in A showing new lesions in left basal ganglia and frontal lobe. Susceptibility weighted images in B showing hypointense rim in all the lesions suggesting hemorrhagic walls of the lesions. Postcontrast T1W images in C showing multiple ring enhancing lesions with increase in size compared to previous scans

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  Discussion Top


In S. apiospermum infection immunocompetent and immunocompromised humans can be affected. Central nervous system (CNS) involvement by the fungus is often fatal and commonly causes abscess, meningitis, ventriculitis and vascular invasion leading to infarction. [1],[2] CNS infection can be hematogenous or spread from paranasal sinuses/ears, or direct inoculation through surgery/trauma. [3],[4],[5],[6]

In our case, after surgical fenestration of ventricular loculation, the patient developed fever and seizures followed by hemiparesis. CT imaging showed diffuse hemispheric involvement mimicking hemiconvulsion hemiplegia epilepsy syndrome. Unilateral hemispheric cytotoxic edema is characteristically described in hemiconvulsion hemiplegia epilepsy syndrome which was observed in our patient. [7]

MRI showed unilateral hemispheric edema (restricted diffusion) with ring enhancing lesions. This was confined to one cerebral hemisphere which later spread to the other hemisphere. Reason behind this could be direct surgical inoculation rather than hematogenous spread as infection was initially confined to one hemisphere and became evident within 4 days of surgery. However, the exact cause cannot be confirmed. Usually CNS infection takes few weeks to develop after submersion injury by hematogenous spread and is of insidious onset. [8]

Lesions in our case showed predominant hypointensity in the center on T2W images and slight hyperintensity on T1W images. Walls of the lesion were hypointense on T1W and hyperintense on T2W which showed as ring enhancement on contrast examination. Susceptibility weighted imaging showed blooming artifacts predominantly in the wall of the lesion due to hemorrhage. In differentiation of pyogenic, tubercular and fungal abscesses, Luthra et al. have described T2W hypointensity of projections of fungal abscess and enhancing wall of the fungal abscess without enhancement of the projections. [9] In our case central non-enhancing hypointensity on T2W of the lesion could be due to fungal hyphal projections with necrosis (confirmed on histopathology) and peripheral enhancing inflammatory wall. All the lesions showed hemorrhage probably due to extensive vascular invasion of the fungus and abscess formation since S. apiospermum is known to have high affinity to blood vessels like aspergillosis. [2],[10]

Our case of S. apiospermum abscess is unique in many ways. First, symptoms of infection started immediately after surgery in the form of fever and seizures which became evident on second day by CT scan showing hemispheric edema mimicking hemiconvulsion hemiplegia epilepsy syndrome. Diffusion weighted imaging showed restricted diffusion in right cerebral hemisphere with multiple hemorrhagic ring enhancing lesions which became evident on fourth day and all confined initially on one hemisphere which rapidly spread to other hemisphere. It can be a combination of hemispheric cytotoxic edema with superimposed infection. These atypical imaging features in our case led to delay in diagnosis. Although 75% of all CNS infections due to S. apiospermum do not survive even with appropriate antifungal treatment, [11] voriconazole may prove to be useful in few cases if diagnosed early. [3] Recently, Wilson et al. have described a similar case of S. apiospermum in an immunocompetent elderly patient with chronic obstructive lung disease and silicosis and have mentioned possible association of silicosis and S. apiospermum. There was delay in diagnosis in their patient also due to rarity of fungal infection like S. apiospermum. [12]


  Conclusion Top


Scedosporium apiospermum can cause fatal multiple brain hemorrhagic abscesses. Imaging features may be atypical and needs to be identified earlier to initiate appropriate treatment. We also suggest initiation of antifungal treatment in a patient of brain infection not responding for aggressive conventional antibacterial treatment.


  Acknowledgement Top


Microbiology Department, Vikram Hospital

 
  References Top

1.
Alexopoulos C, Mims C, Blackwell M. Introductory mycology. New York: Wiley and Sons; 1996.  Back to cited text no. 1
    
2.
Kwon-Chung KJ, Bennet JE. Medical mycology. Philadelphia: Lea and Febiger; 1992. p. 678-94.  Back to cited text no. 2
    
3.
Nesky MA, McDougal EC, Peacock JE Jr. Pseudallescheria boydii brain abscess successfully treated with Voriconazole and surgical drainage: Case report and literature review of central nervous system pseudallescheriasis. Clin Infect Dis 2000;31:673-7.  Back to cited text no. 3
    
4.
Chanqueo L, Gutiérrez C, Tapia C, Silva V, Razeto L, Misad C. Scedosporium apiospermum rhinosinusal infection in an immunocompetent host. Rev Chilena Infectol 2009;26:453-6.  Back to cited text no. 4
    
5.
Acharya A, Ghimire A, Khanal B, Bhattacharya S, Kumari N, Kanungo R. Brain abscess due to Scedosporium apiospermum in a non immunocompromised child. Indian J Med Microbiol 2006;24:231-2.  Back to cited text no. 5
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6.
Gopinath M, Cherian A, Baheti NN, Das A, Antony M, Sarada C. An elusive diagnosis: Scedosporium apiospermum infection after near-drowning. Ann Indian Acad Neurol 2010;13:213-5.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Freeman JL, Coleman LT, Smith LJ, Shield LK. Hemiconvulsion-hemiplegia-epilepsy syndrome: Characteristic early magnetic resonance imaging findings. J Child Neurol 2002;17:10-6.  Back to cited text no. 7
    
8.
Wilichowski E, Christen HJ, Schiffmann H, Schulz-Schaeffer W, Behrens-Baumann W. Fatal Pseudallescheria boydii panencephalitis in a child after near-drowning. Pediatr Infect Dis J 1996;15:365-70.  Back to cited text no. 8
    
9.
Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR Imaging and Proton MR Spectroscopy. AJNR Am J Neuroradiol 2007;28:1332-8.  Back to cited text no. 9
    
10.
Kershaw P, Freeman R, Templeton D, DeGirolami PC, DeGirolami U, Tarsy D, et al. Pseudallescheria boydii infection of the central nervous system. Arch Neurol 1990;47:468-72.  Back to cited text no. 10
    
11.
Kantarcioglu AS, Guarro J, de Hoog GS. Central nervous system infections by members of the Pseudallescheria boydii species complex in healthy and immunocompromised hosts: Epidemiology, clinical characteristics and outcome. Mycoses 2008;51:275-90.  Back to cited text no. 11
    
12.
Wilson HL, Kennedy KJ. Scedosporium apiospermum brain abscesses in an immunocompetent man with silicosis. Med Mycol Case Rep 2013;2:75-8.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Introduction
Case Report
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