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Department of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, China
Requests for reprints should be addressed to Yi Guo, MD, Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China.
A 34-year-old woman undergoing treatment for systemic lupus erythematosus and type 2 diabetes presented to the neurosurgery department with a 2-week history of intermittent epileptic seizures. On examination, she had Cushing signs including moon face and purple stretch marks on the abdomen and thighs. Nervous system examination revealed no abnormality. Magnetic resonance imaging of the head revealed a ring-enhancing lesion with massive edema in the left frontal lobe (Figure A). Repeat examination of the cerebrospinal fluid and the peripheral blood did not detect definite pathogens. Despite empirical antibiotic therapy with meropenem and vancomycin, her disease progressed. Microscopic neurosurgery was then performed and the frontal lesion was resected. Aspergillus fumigatus was reported by culture (Figures B and C, 400×) and was confirmed by the next-generation sequencing. The patient underwent an 8-week adjuvant treatment with intravenous voriconazole, and her symptoms disappeared.
FigureBrain abscesses caused by Aspergillus fumigatus. (A) Magnetic resonance imaging of the head revealed a ring-enhancing lesion in the left frontal lobe with massive surrounding edema. (B) Culture of A. fumigatus. (C) Lactophenol cotton blue staining of A. fumigatus.
Aspergillus, always found in air, soil, and organic matter, is an opportunistic ubiquitous fungus that enters the human body mainly through inhalation. A. fumigatus is one of the most common Aspergillus species responsible for infections among patients undergoing transplantation, patients with chronic neutropenia, and patients receiving high doses of steroids.
Brain abscess has a relatively low incidence of <1 per 100,000 individuals worldwide per year. Pathogens that cause brain abscess include bacteria, fungi, and parasites.
Although the relatively impermeable blood-brain barrier protects the brain from being infected, invasion of Aspergillus into the brain occurs. However, it is extremely rare and can be seen in patients with severe immune defects who have neutrophil or macrophage dysfunction.
Because high mortality rates accompany Aspergillus brain abscess, or brain aspergillosis, early diagnosis saves lives; however, it is difficult to satisfy an accurate diagnosis at an early stage because of the nonspecific manifestations. Brain aspergillosis can present with various neurological manifestations. Like this patient with systemic lupus erythematosus, the symptom of intermittent epileptic seizures can be initially suspected as lupus encephalopathy. Magnetic resonance imaging of the head is necessary for immunocompromised patients with neurological defects to assist in differential diagnosis.
The management of brain aspergillosis remains controversial. Due to the poor penetration of the antifungal drugs, antifungal therapy alone for brain aspergillosis has a poor outcome. Surgical resection of the focal intracranial lesion combined with adjuvant drug treatment with voriconazole seems to be the optimal choice that significantly reduces the mortality rate.
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