SESSION TYPE: Infectious Disease Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Neurosarcoidosis, treated with steroids, leads to immunocompromised state. This can cause opportunistic infections. Our case demonstrates brain abscess with rare biplolaris pathogen.
CASE PRESENTATION: 35-year-old African American male presented with three-day history of altered mental status, dysarthria and disequilibrium. Fifteen months prior, he was evaluated for dizziness, headache, chest pain and hearing loss. Work-up reveled abnormality on brain magnetic resonance imaging (MRI) along with multiple pulmonary nodules and hilar lymphadenopathy. Bronchoscopy revealed non-caseating granulomas. Stage 2 pulmonary and neurosarcoidosis was diagnosed and treatment with dexamethasone was initiated and maintained. Examination reveled right facial drooping and right-sided hearing deficit. MRI revealed six ring-enhancing lesions in the cerebral cortex (Figure 1). Work-up included lumbar puncture, blood cultures, and investigations for toxoplasma, cryptococcus, and tuberculosis, all yielding negative results. Biopsy of the lesions revealed yellow purulent fluid showing septate hyphae identified as Bipolaris species. Patient responded to intravenous (IV) voriconazole and was discharged on oral voriconazole. Repeat MRI showed interval increase in lesion size. Patient was readmitted and started on IV voriconazole and liposomal amphotericin B. Intracerbral abscesses were drained by neurosurgery. Patient improved with IV therapy over 15 days and was discharged on oral voriconazole for a time course presumed to be months to be managed based on improvement of clinico-radiological features.
DISCUSSION: Genus bipolaris, usually found in plant debris and soil, causes phaeohyphomycosis. Most isolated species are bipolaris specifera, biploaris austaliensis, and bipolaris hawaiiensis(1). Reported infections with bipolaris include sinusitis, keratitis, endophthalmitis, and peritonitis(1). Though an infection of immunocompromised host, cases of bipolaris infection have been reported in immunocompetent host as well. In a review of 101 CNS cases of phaeohyphomycosis, 6 were caused by bipolaris: 2 brain abscesses, 3 meningitis and 1 encephalitis. From the 6: 2 immunocompromised, 1 head trauma, and 1 had neurosurgical intervention, 2 immunocompetent (brain abscesses) (2) . CNS phaeohyphomycoses has a mortality of 100% if untreated and 65% for those who are treated3. The current treatments available include surgical debridement, combination anti-fungal therapy and immunotherapy(3).
CONCLUSIONS: This potentially fatal but treatable disease must be kept in mind when investigating an immunocompromised patient.
1) Revankar SG, Sutton DA. Melanized fungi in human disease. Clin Microbiol Rev. 2010 Oct;23(4):884-928
2) Revankar SG, Sutton DA, Rinaldi MG. Primary central nervous system phaeohyphomycosis: a review of 101 cases. Clin Infect Dis. 2004 Jan;38(2):206-16
3) Li DM, de Hoog GS. Cerebral phaeohyphomycosis-a cure at what lengths? Lancet Infect Dis. 2009 Jun;9(6):376-83.
DISCLOSURE: The following authors have nothing to disclose: Monaliben Patel, Nayan Desai, Alicia Menezes, Anuradha Mookerjee
No Product/Research Disclosure InformationCooper University Hospital, Camden, NJ