case 2012-7
DESCRIPTION
Case 2012-7. Kimberly Stogner-Underwood, MD Andrea Gilbert Jelinek, DO Christine E. Fuller, MD. Drs Stogner-Underwood, Jelinek, and Fuller have nothing to disclose. Clinical History. 22 y/o male inmate Neurologic symptoms x 2 months - PowerPoint PPT PresentationTRANSCRIPT
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Case 2012-7Kimberly Stogner-Underwood, MDAndrea Gilbert Jelinek, DOChristine E. Fuller, MD
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Drs Stogner-Underwood, Jelinek, and Fuller have nothing to disclose.
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Clinical History
22 y/o male inmate Neurologic symptoms x 2 months MRI – 10 cm enhancing frontotemporal mass
with extension into corpus callosum HIV negative, and not otherwise
immunocompromised
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Neuroimaging - T1 Pre- and Post-Contrast, T2 FLAIR
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Clinical History
Stereotactic biopsy of frontal mass Lung lesion RUL – HSV+ on cytology Blood, Tissue, CSF, and Respiratory cultures
negative
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Clinical History
Symptoms progressed despite treatment Increased mass effect Hemorrhage at base of brain Death
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Autopsy Findings Dense clotted material
covered ventral brainstem and adjacent cerebellum
Right cerebellar hemisphere infarct
Right occipital lobe contained a firm, tan-yellow lesion
Large necrohemorrhagic lesion right frontotemporal region; hemorrhage in right lateral, 3rd, and 4th ventricles
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Comments…..
Differential Diagnosis Additional studies?
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Brain mass
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GMS
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Lung mass
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Culture
Few Dematiaceous Mold Identified by sequencing
Bipolaris species
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Diagnosis
Fungal abscess with Bipolaris species aka Cerebral Phaeohyphomycosis or
Chromoblastomycosis
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Cerebral Phaeohyphomycosis
Caused by dematiaceous fungi Soil, plants
Neurotropism in some species High mortality rate
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Cerebral Phaeohyphomycosis
CNS infection in immunocompetent or immunocompromised patients Immunocompromised – Disseminated disease Immunocompetent – CNS only
2nd-3rd decade M:F = 3:1
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Cerebral Phaeohyphomycosis
Can mimic a neoplasm or bacterial abscess on imaging Ring-enhancing lesion Can show irregular enhancement as seen in this
case
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Sources of CNS Infection
Hematogenous spread – Most common Lung, Paranasal sinuses Initial infection may be asymptomatic Other sources of fungemia – Skin infection, IV
drug use Direct extension
Paranasal sinuses Trauma/Surgery
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Fungi Causing Cerebral Phaeohyphomycosis Cladophialophora bantiana – Most common Exophiala dermatitidis Rhinocladiella mackenziei Bipolaris spicifera and other Bipolaris species Ochroconis gallopavum Fonsecaea species Chaetomium species Curvularia species Neoscytalidium dimidiatum
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Histologic Features
Melanin pigment in cell wall Thick-walled branched and unbranched
hyphae with terminal vesicular structures Budding forms Structures are seen alone or in chains within
foreign body type giant cells Histiocytes, lymphocytes, and plasma cells
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Bipolaris species Isolated from plant and soil
debris Main pathogenic species:
specifica, australiensis, hawaiiensis
Infects both immunocompetent and compromised hosts
Colonies: fast growing, wooly, olive green to black
Septate brown hyphae Poroconidia: cylindrical, 3-6
fused cells; geniculate growth pattern
http://www.doctorfungus.org/thefungi/bipolaris.php
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So how did our patient pick up Bipolaris? Job in prison: cleaning showers and toilets
Outside in “the yard”
Gift from some friends or the Warden
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References
Flizzola, et al. Phaeohyphomycosis of the central nervous system in immunocompetent hosts: report of a case and review of the literature. Int J Infect Dis. 2003 Dec;7(4):282-6.
Li, DM, de Hoog, GS. Cerebral phaeohyphomycosis – a cure at what lengths? Lancet Infect Dis. 2009 Jun;9(6):376-83.
Rosow, L., et al. Cerebral phaeohyphomycosis caused by Bipolaris spicifera after heart transplantation. Transpl Infect Dis. 2011 Aug;13(4):419-23.
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