Case Report Treatment of a Brain Abscess Caused By
Total Page：16
File Type：pdf, Size：1020Kb
SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH CASE REPORT TREATMENT OF A BRAIN ABSCESS CAUSED BY SCEDOSPORIUM APIOSPERMUM AND PHAEOACREMONIUM PARASITICUM IN A RENAL TRANSPLANT RECIPIENT Noppadol Larbcharoensub1, Piriyaporn Chongtrakool2, Chewarat Wirojtananugoon3, Siriorn P Watcharananan4, Vasant Sumethkul5, Atthaporn Boongird6 and Sopon Jirasiritham7 1Division of Anatomical Pathology, 2Division of Microbiology, Department of Pathology, 3Department of Radiology, 4Division of Infectious Disease, 5Division of Nephrology, Department of Medicine, 6Division of Neurosurgery, 7Division of Vascular/transplant Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Abstract. Cerebral mycosis is a significant cause of morbidity among immu- nocompromised populations. We present here a case of cerebral infection with Scedosporium apiospermum and Phaeoacremonium parasiticum in a 49-year-old renal transplant recipient. Fourteen years after renal transplantation, the patient pre- sented with invasive pulmonary aspergillosis treated with intravenous liposomal amphotericin B. The patient had clinical and radiographic improvement. However, 6 weeks later, the patient presented with cerebral infection. Magnetic resonance imaging revealed multiple rim enhancing brain abscesses. Brain and cerebrospinal fluid cultures ultimately grew Scedosporium apiospermum and Phaeoacremonium parasiticum. The patient was treated with voriconazole for 6 months and had clinical and radiologic improvement. We believe this is the first reported case of co-infection of the brain with scedosporiosis and phaeohyphomycosis in a renal transplant recipient, who had received intravenous liposomal amphotericin B. Voriconazole may represent a new therapeutic option for these simultaneous infections in the brain. Keywords: brain abscess, Pseudallescheria boydii, Scedosporium apiospermum, Pha- eoacremonium parasiticum, Phialophora parasitica Correspondence: Noppadol Larbcharoensub, INTRODUCTION Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Scedosporium apiospermum with its Rama VI Road, Ratchathewi, Bangkok 10400, sexual anamorph Pseudallescheria boydii Thailand. and Phaeoacremonium parasiticum (previ- Tel: +66 (0) 2354 7277; Fax: +66 (0) 2354 7266 ously named as Phialophora parasitica) are E-mail: [email protected] ubiquitous filamentous fungi commonly 484 Vol 44 No. 3 May 2013 S. APIOSPERMUM AND P. PARASITICUM IN A RENAL TRANSPLANT RECIPIENT found in soil, sewage, and water (Castiglioni et al, 2002). Eumyce- toma is the most common manifes- tation with both fungal organisms (Fincher et al, 1998; Castiglioni et al, 2002). They rarely infect the cen- tral nervous system causing brain abscesses. S. apiospermum brain abscesses have been reported and are usually seen in organ transplant recipients who receive immunosup- Pre-operative MRI pressive agents (Campagnaro et al, 2002; Castiglioni et al, 2002; Rogasi et al, 2007; Satirapoj et al, 2008). Only one case of a brain abscess caused by P. parasiticum has been reported (McNeil et al, 2011). Herein, the authors report the clinical, radio- logical, histopathologic and micro- biologic features of co-infection in the brain with S. apiospermum and P. parasiticum in a renal transplant Two months post-treatment recipient. This case report was ap- proved by the committee on human Fig 1–MRI shows multiple rim enhancing abscesses rights related to research involving with perilesional vasogenic edema (1A: T1 axial view, 1B: T1 coronal view). Two months later the human subjects at the Faculty of MRI shows resolution of the brain abscesses (1C: Medicine Ramathibodi Hospital, T1 axial view, 1D: T1 coronal view). Mahidol University (ID02-54-55). CASE REPORT with intravenous liposomal amphoteri- cin B. His pulmonary infection improved A 49-year-old man underwent ca- clinically and radiologically. However, daveric renal transplantation in 1993. The within 6 weeks, he developed fever, in- underlying diagnosis of this patient was tense headache over 72 hours and right- chronic glomerulonephritis. His renal sided hemiparesis. function was stabilized. He was taking daily immunosuppression with tacroli- An upper motor neuron lesion was mus (FK506) and prednisolone. Fourteen noted unilaterally. Laboratory studies years later, six weeks prior to admission, revealed a hemoglobin of 8.9 g/dl, a he- he contracted pulmonary aspergillosis. matocrit of 26.4%, a white blood cell count Serum galactomannan antigen was posi- of 13,500/mm3, a platelet count of 203,000/ tive. Bronchoscopy was performed and mm3 and a serum creatinine of 2.8 mg/dl. histopathology revealed acute angle An emergency computed tomography dichotomous branching septate hyphe. (CT) of the brain revealed multiple well- The lung tissue culture grew Aspergillus defined, thick walled hypodense lesions fumigatus. He was subsequently treated (18 Hounsfield units) with perilesional Vol 44 No. 3 May 2013 485 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH with beaded yeast-like forms. A cultures of the brain abscess yielded S. apiospermum and P. parasiticum. S. apiospermum grew rapidly on Sabouraud’s agar and produced floccose colonies that turned from white to dark-gray and smoky brown in 4 days (Fig 2). A slide culture showed unique morphological characteristics of this mould, presenting with hyaline, septate hyphae (2-4 µm in diameter), with solitary, ovoid unicellular conidia, cut off at the base and borne terminally on elongated simple conidiophores. Fig 2–A 5-day-old fully grown colony of S. apiospermum on Sabouraud dextrose agar (2A). The colony was Concurrently, a graphium syn- initially cottony and white but turned grey when anamorph was also seen showing older. The reverse was grey to black. A scedospo- erect, stiff, olive-brown bundles of rium asexual conidiation of S. apiospermum shows hyphae, terminating in a brush of hyaline, septate hyphae and conidiogenous cells at slender conidiogenous cells with the tip of the annellidic-flask-shaped conidiophores annellidic conidiation. This type (2B, Lacto phenol cotton blue stain, x400). A 21-day- of conidiation produced smaller, old colony of P. parasiticum on Sabouraud dextrose less pigmented and more slender agar showing black, initially velvety radiating fur- conidia compared with those of rows, later developing hyphal fascicles, olivaceous- the scedosporium type. Both were grey with a blackish reverse (2C). The sections of truncated at their base, although the brain abscess revealed beaded yeast-like fungi, the scedosporium types were morphologically consistent with P. parasiticum (2D, GMS stain, x200). more dominant. With the above mentioned characteristics, the iso- late was phenotypically identified as S. apiospermum. edema involving the centrum semiovale, A culture of the cerebrospinal fluid left corona radiata, right occipital lobe (CSF) specimen in this patient yielded and left splenium of the corpus callosum. a dark-pigmented colony after 5 days of Magnetic resonance imaging (MRI) of the inoculation at 25oC. This moist colony brain revealed multiple rim enhancing grew moderately slowly and attained a cerebral abscesses with perilesional va- diameter of 2-3 cm by 3 weeks of incuba- sogenic edema (Fig 1). A cerebral abscess tion. Its texture became wooly to velvety was diagnosed and surgical drainage and heaped. The obverse was dark black was performed and samples sent for and the reverse was iron-gray to black. microbiology and histopathology. These Microscopic features using conventional showed multiple fungal elements with slide culture techniques demonstrated dichotomous branching septate hyphae dark-walled, septate (up to 5 µm) hyphae, and irregular, septate hyphal elements bearing rather long phialides located 486 Vol 44 No. 3 May 2013 S. APIOSPERMUM AND P. PARASITICUM IN A RENAL TRANSPLANT RECIPIENT terminally or laterally along the hyphae. threatening. The fungal species causing The collarettes could hardly be seen due brain abscesses in solid organ transplant to their tiny, narrow parallel contours, recipients is changing. S. apiospermum characteristics that clearly differentiated preferably affects solid organ transplant them from the widely known Phialophora recipients, either with pathologic host verrucosa and Pleurostomophora richardsiae defense alterations or those with severe (previously Phialophora richardsiae). The drug-induced immunosuppression (Cam- conidia were unicellular, hyaline, smooth pagnaro et al, 2002; Castiglioni et al, 2002; and cylindrical in shape. These conidia Rogasi et al, 2007; Satirapoj et al, 2008). S. sometimes accumulated in masses at the apiospermum brain abscesses have been apices of the phialides, giving the appear- reported and usually seen in kidney ance of a vase with a bundle of flowers. transplant recipients who receive immu- The length of the phialides seemed rather nosuppressive agents (Campagnaro et al, long, longer than 20 µm and spine-shaped, 2002; Castiglioni et al, 2002; Rogasi et al, which were the characteristics used for 2007; Satirapoj et al, 2008). P. parasiticum is differentiate it from Pleurostomophora an uncommon emerging fungus causing repens (previously Phialophora repens) in cutaneous and subcutaneous infection in which the phialides are shorter than 20 the renal transplant recipients (Fincher µm. Penicillate bushes of phialides, a et al, 1988). Acquisition is usually through unique characteristic of P. repens, could not skin trauma or contamination of wounds. be found