Maimonides Medical Center, Brooklyn, NY
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Fungal brain abscesses are rare causes for altered sensorium and they are often resistant to treatment, resulting in high morbidity and mortality. Brain abscesses are commonly caused due to fungal organisms, especially Candida species.
CASE PRESENTATION: A 53 year old man with past medical history of diabetes presented to the emergency department after being found on the floor. The patient was alert and oriented only to place and person. Patient was diagnosed with diabetic ketoacidosis, acute kidney injury, acute pancreatitis for which he was appropriately treated. Computed tomography (CT) abdomen was consistent with left pyelonephritis and prostatic abscess. Initial urine, blood and stool cultures revealed Candida albicans. Intravenous micafungin and fluconazole were instituted based on culture reports. HIV test was negative. Magnetic resonance Imaging (MRI) of brain demonstrated ring enhancing lesions with vasogenic edema and abnormal restricted diffusion (Figure 1A & 1B). Lumbar puncture was noncontributory. Treatment was changed from micafungin to liposomal amphotericin B with fluconazole with which patient demonstrated both clinical and radiological improvement (Figure 2A &2B). Further evaluation showed an enhancing tongue mass with cervical lymphadenopathy. Biopsy proved the presence of Stage IVA squamous cell cancer of the tongue. Early neoplastic markers, Anti-Hu and Anti-Yo antibodies were negative.
DISCUSSION: Candida cerebral abscess are mostly diagnosed at autopsy. An autopsy series demonstrated that up to 6% of patients with systemic candidiasis have evidence of undiagnosed CNS involvement as well. Risk factors include penetrating trauma, neurosurgical intervention, IV drug abuse, corticosteroid use, and malignancies. Candida brain abscesses can also be secondary to the infection of the adjacent structures or be secondary to hematogenous spread from endocarditis, intrabdominal or genitourinary tract infections as in our case. Risk factors present in our patient included diabetes mellitus and malignancy. Only 55% of blood cultures and 23% of lumbar puncture are positive for Candida1. CT and MRI are the preferred imaging modalities for diagnosing brain lesions and monitoring response to therapy. A definitive diagnosis can be achieved from stereotactic brain biopsy, although this is rarely reported. Infectious diseases society of America recommends liposomal Amphotericin B with flucytosine for several weeks to manage Candida brain abscess, switching to azole based therapy.
CONCLUSIONS: This case demonstrates the need to consider fungal brain abscesses, as differentials for altered mental status and that with the aid of MRI and effective management, patients may improve neurologically as seen in this patient.
Reference #1: Andrea M. Fennelly, Amy K. Slenker, Lara C. Murphy, Michael Moussouttas, Joseph A. Desimone. Candidacerebral abscesses: a case report and review of the literature.Med Mycol (2013) 51 (7): 779-784.
DISCLOSURE: The following authors have nothing to disclose: Shyam Shankar, Sushilkumar Gupta, Ishan Malhotra, Mangalore Amith Shenoy, Hatem Desoky, Prarthna Chandar, William Pascal, Stephan Kamholz, Richard Periut, Chanaka Seneviratne, Yizhak Kupfer
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