G Model NEURAD-681; No. of Pages 8 ARTICLE IN PRESS Journal of Neuroradiology xxx (2017) xxx–xxx Available online at ScienceDirect www.sciencedirect.com Original Article CNS aspergilloma mimicking tumors: Review of CNS aspergillus infection imaging characteristics in the immunocompetent population a b,∗ c a Devendra Kumar , Pankaj Nepal , Sumit Singh , Subramaniyan Ramanathan , Maneesh d e e f Khanna , Rakesh Sheoran , Sanjay Kumar Bansal , Santosh Patil a Al wakra Hospital, Hamad Medical Corporation, Doha, Qatar b Metropolitan Hospital Center, New York Medical College, NY, USA c University of Alabama, Alabama, USA d Hamad Medical Corporation, Doha, Qatar e Neurociti Hospital, Ludhiana, Punjab, India f Department of Radiodiagnosis, JN medical College, Karnataka, India a r t i c l e i n f o a b s t r a c t Article history: Background and purpose. – CNS Aspergillosis is very rare and difficult to diagnose clinically and on imaging. Available online xxx Our objective was to elucidate distinct neuroimaging pattern of CNS aspergillosis in the immunocompe- tent population that helps to differentiate from other differential diagnosis. Keywords: Methods. – Retrospective analysis of brain imaging findings was performed in eight proven cases of cen- Central nervous system (CNS) tral nervous system aspergillosis in immunocompetent patients. Immunocompetent status was screened Aspergillosis with clinical and radiological information. Cases were evaluated for anatomical distribution, T1 and T2 sig- Immunocompetent nal pattern in MRI and attenuation characteristics in CT scan, post-contrast enhancement pattern, internal inhomogeneity, vascular involvement, calvarial involvement and concomitant paranasal, cavernous sinus or orbital extension. All patients were operated and diagnosis was confirmed on histopathology. Results. – The age range was 19–50 years with mean age of 33.7 years. Concomitant sinonasal disease was seen in six patients (75%). Three patients had orbital extensions. Most of the lesions (n = 7) were pro- foundly hypointense in T2-weighted imaging. The most common enhancement pattern was bright, solid and homogenous enhancement (n = 7). Cavernous extension with ICA encasement was always associated with paranasal sinus disease. Six patients showed demineralization or complete resorption of involved bone. All of the fungal masses appear hyperdense on available CT scan images. Conclusion. – CNS aspergillus infection in immunocompetent patients has distinct imaging features as compared to CNS aspergillosis in immunocompromised patients. A high index of suspicion in proper clinical settings, even with immunocompetent status and typical imaging features allow us to diagnose CNS aspergillosis in such patients. © 2017 Elsevier Masson SAS. All rights reserved. Introduction of central nervous system (CNS) aspergillosis can be attributed to the use of immunosuppressive drugs, increased number of Aspergillosis is caused by ubiquitous and saprophytic fun- solid organ and hematological malignancies as well as spread of gus of Aspergillus species. The most common human pathogen is the human immunodeficiency virus (HIV) [2,3]. CNS aspergillo- Aspergillus fumigatus. However, Aspergillus flavus and Aspergillus sis is a rare infection usually reported in immunocompromised niger have been recorded occasionally [1]. Increasing frequency patients. The prognosis of CNS aspergillosis in such patients is dis- mal with 85–100% mortality [4]. CNS aspergillosis is extremely rare in immunocompetent individuals [5]. CNS infection can occur ∗ by hematogenous dissemination remotely from the lungs, direct Corresponding author. Metropolitan Hospital Center, New York City Health extension from adjacent paranasal sinuses, middle ear cavity and Metropolitan Hospital Center, 1901, First Avenue, New York, NY 10029, USA. E-mail addresses: [email protected] (D. Kumar), [email protected] orbits or from post-surgical procedures [6,7]. Clinical diagnosis is (P. Nepal), [email protected] (S. Singh), [email protected] challenging due to non-specific presenting signs and symptoms (S. Ramanathan), [email protected] (M. Khanna), [6]. A prompt diagnosis leading to surgical resection and aggres- [email protected] (R. Sheoran), [email protected] sive antifungal treatment is required to limit the high mortality (S.K. Bansal), [email protected] (S. Patil). https://doi.org/10.1016/j.neurad.2017.11.001 0150-9861/© 2017 Elsevier Masson SAS. All rights reserved. Please cite this article in press as: Kumar D, et al. CNS aspergilloma mimicking tumors: Review of CNS aspergillus infection imaging characteristics in the immunocompetent population. J Neuroradiol (2017), https://doi.org/10.1016/j.neurad.2017.11.001 G Model NEURAD-681; No. of Pages 8 ARTICLE IN PRESS 2 D. Kumar et al. / Journal of Neuroradiology xxx (2017) xxx–xxx Table 1 Imaging features of fungal granuloma. S.N Age/sex Localization T2 feature Enhancement pattern Vascular involvement Bone involvement 1 37/M Orbital apex, PS T2 hypointense Solid Encased but patent ICA RD and CR and CS 2 50/F Orbital apex, PS IFG, hypointense Solid, PME Encased but patent ICA RD and CR and CS 3 24/M MCF, PS T2 hypointense rim Solid NA NA 4 40/F MCF, PS, CS IFG, T2 hypointense Solid, PME Encased but patent ICA RD and CR 5 24/M MCF, PS, CS IFG, T2 hypointense Solid Encased but patent ICA RD and CR 6 20/F ACF, CS, pituitary IFG, T2 hypointense Solid, PME Thrombosed ICA with MCA infarct RD and CR 7 30/M PS, Mastoid, CS T2 hyperintense Diffuse heterogeneous Thrombosed ICA with ACA and Permeative destruction of enhancement MCA watershed base of skull bones 8 45/M ACF, MCF IFG, T2 hypo Solid, PME NA NA M: male; F: female; PS: paranasal sinus; CS: cavernous sinus; ACF: anterior cranial fossa; MCF: middle cranial fossa; IFG: intracranial fungal granuloma; RD: reactive demineralization; CR: complete resorption; PME: pachymeningeal/dural enhancement. • associated with the infection. Moreover, the classical neuroimag- axial diffusion-weighted echo planar sequence (3116 ms ing findings of CNS aspergillosis described in immunocompromised TR/81 ms TE/2NEX) and; • patients are often not seen in immunocompetent individuals mak- post-contrast T1-weighted images were obtained in three ing the diagnosis even more difficult. orthogonal planes after administration of 0.2 mL/kg of gadobe- Recognizing the typical and atypical imaging features of CNS nate dimeglumine (Multihance; Bracco Diagnostics Incorpora- aspergillosis allows for early and aggressive management of oth- tion, Monroe, NJ, USA). erwise rapidly fatal infections. As we know CNS aspergillosis in immunocompetent individuals is very rare, although few of the In all sequences, except susceptibility-weighted sequence, the studies and cases have been reported in the literature [1,5,7–12,14], slice thickness was 5 mm and interslice gap of 1–2 mm. Due to however the discussion of a distinct neuroimaging pattern of CNS volume acquisition, the slice thickness in susceptibility-weighted aspergillosis in immunocompetent population and its difference sequences was 1 mm. In all sequences, the field of view was 16 to with immunocompromised patients have not been specifically 24 cm and matrix size was 200–256 × 170–198, except DWI, which elaborated. In this article, we describe magnetic resonance imaging had an image matrix of 144 × 113. (MRI) and computed tomography (CT) findings of biopsy-proven CT of the head was performed in 3 patients. Routine CT head CNS aspergillus infection in eight immunocompetent patients. Case were obtained using GE 16 slice multidetector scanner (General history and imaging findings of five patients are discussed in detail. Electric, Waukesha, Wisconsin, USA). The scanning parameters for head CT were 120 Kvp and variable mA depending on SD setting. Three neuroradiologists with more than 5 years of experience Material and methods in neuroimaging reviewed images by consensus. All cases were evaluated for anatomical distribution; T1 and T2 signal pattern The institutional review board approved this retrospective in MRI and attenuation characteristics in CT scan, post-contrast study. We identified and included eight immunocompetent enhancement pattern, internal inhomogeneity, vascular involve- patients from neuroradiology and surgery databases from January ment, calvarial involvement and concomitant paranasal, cavernous 2010 to January 2014 for a period of 4 years. The clinical data were sinus or orbital extension. All patients were operated and diagnosis obtained from electronic medical records. Immunocompetent sta- was confirmed on histopathology. tus was screened with clinical and radiological information. The patients in our study had not received chemotherapy, steroids, Case review or other immunosuppressive agents. Patients were not included if they had a diagnosis of any known malignancy, chronic liver The clinical detail and imaging features of all patients are sum- disease, end-stage renal failure, diabetes mellitus, HIV infection, marized in Table 1. In the interest of scope of the article and to or congenital immunodeficiency. Patients not meeting the criteria avoid repetition of imaging findings, we describe the case history were excluded. and imaging findings of 5 out of 8 patients in detail. MRI brain with contrast was performed in all patients. CT scan of head was done on 3 patients. All MRI scans were performed on 1.5-T Case 1 Achieva scanners (Philips Healthcare, Andover, MA, USA). Standard A 17-year-old female presented with generalized acute 8-channel head