- Departments of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico,
- Department of Internal Medicine, Instituto Mexicano del Seguro Social, León, Mexico.
- Departments of Neuroinfectology, National Institute of Neurology and Neurosurgery, Mexico,
Marcos Vinicius Sangrador-Deitos
Departments of Neuroinfectology, National Institute of Neurology and Neurosurgery, Mexico,
DOI:10.25259/SNI_506_2019Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Marcos Vinicius Sangrador-Deitos, Jimena Alejandra González Olvera, Heidy Adames Espinal, Graciela Cárdenas Hernández, Verónica Angeles Morales, José Luis Soto Hernandez. Fungal mycotic aneurysm in a patient with Aspergillus terreus chronic meningoencephalitis. 06-Jun-2020;11:139
How to cite this URL: Marcos Vinicius Sangrador-Deitos, Jimena Alejandra González Olvera, Heidy Adames Espinal, Graciela Cárdenas Hernández, Verónica Angeles Morales, José Luis Soto Hernandez. Fungal mycotic aneurysm in a patient with Aspergillus terreus chronic meningoencephalitis. 06-Jun-2020;11:139. Available from: https://surgicalneurologyint.com/surgicalint-articles/10067/
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.
Keywords: Aneurysm, Aspergillus terreus, Mycotic
In 1885, William Osler was the first to describe an aortic aneurysm secondary to infectious endocarditis.[
We present the case of a 26-year-old non-HIV male with a 1-year background appendectomy, which required epidural anesthesia. After surgery, he presented an insidious headache, requiring mild analgesics for adequate control. In the following weeks, headaches increased and tomographic imaging revealed hydrocephalus. A ventriculoperitoneal shunt was installed for suspicion of neurocysticercosis. Even though treatment was initiated, there was no clinical improvement. Sequentially, during hospital stay, shunt dysfunction occurred twice, for which shunt replacement was performed. Cerebrospinal fluid (CSF) and shunt’s catheter were cultured, identifying a filamentous fungus. CSF and serum galactomannan tests were positive for Aspergillus spp.: 9.4 ng/dl and 5.8 ng/dL, respectively. Intravenous amphotericin B and fluconazole were administered; however, a torpid clinical evolution was observed. The filamentous fungus was finally sequenced as Aspergillus terreus. After a 2-week antifungal scheme, sudden rostrocaudal deterioration appeared. Computed tomography imaging was done, revealing a 70 cc hematoma in the right operculoinsular region, midline shift [
Fungal cerebral MAs are most commonly seen in patients with immunocompromised states, such as AIDS or complicated diabetes mellitus.[
Iatrogenic fungal infections of the central nervous system must be suspected in patients with meningitis and a background of epidural invasive procedures such as anesthesia or any drug administration.[
We present the first case report of a fungal MA of the middle cerebral artery bifurcation caused by A. terreus, a fungus found worldwide in soil. It has been reported to cause pathologic states in immunocompromised patients; however, our patient showed no evidence of immunocompromise whatsoever. Intrathecal inoculation following epidural anesthesia represents the form of transmission, which should be always taken into account with patients presenting this background history. The lethal outcome observed, depicts the intrinsic resistance this pathogen presents for amphotericin, which has been administered to the patient. Even though the wide range of diagnostic studies and treatment strategies, fungal central nervous system infections remain a diagnosis challenge which requires high suspicion and continues to be have one of the highest mortality rates among neurological diseases.
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