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Candida albicans brain abscesses in an injection drug user patient: a case report.

Neves N, Santos L, Reis C, Sarmento A - BMC Res Notes (2014)

Bottom Line: Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy.Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect.This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.

View Article: PubMed Central - PubMed

Affiliation: Infectious Diseases Department, Centro Hospitalar São João and Faculty of Medicine of Porto University, Porto, Portugal. nelianeves@gmail.com.

ABSTRACT

Background: Fungal brain abscess is an uncommon disease, mostly associated with immunocompromised states and poorly controlled diabetes. Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy. Candida species have emerged as the most prevalent etiologic agents of brain abscesses in autopsy studies.

Case presentation: A 46-year-old male with a history of injection drug abuse, chronic hepatitis C and diabetes mellitus presented to the Emergency Department of our hospital following a generalized tonic-clonic seizure without recovery of mental status. On admission, the patient was in coma, febrile, with severe acidemia with respiratory and metabolic acidosis, requiring invasive mechanical ventilation. Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect. Microbiologic studies, including cerebrospinal fluid, blood, sputum and urine cultures, were all negative. A stereotactic brain biopsy was performed and culture of brain specimens revealed Candida albicans. The patient was successfully treated with fluconazole therapy for 48 weeks presenting a good clinical response and a complete radiological resolution of brain abscesses.

Conclusion: Despite advances in diagnostic and therapeutic procedures, fungal brain abscess remains a life-threatening disease with a poor outcome. Successful treatment requires an early diagnosis and usually a combined medical and surgical approach. A long-term antibiotic regimen is a cornerstone of fungal brain abscesses treatment, with the endpoint determined by clinical and neuroimaging response. The authors report an uncommon case of successfully treated Candida albicans brain abscesses with anti-fungal therapy consisting of fluconazole alone. This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.

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Related in: MedlinePlus

Brain magnetic resonance imaging(MRI)on day 2. Showed multiple rounded expansive lesions in basal ganglia region predominantly on the left side and in subcortical right parietal region with prominent oedema, resulting in modelling of lateral ventricles, slight deviation of middle line to the right side and reduction of sulci dimensions (A: T2 flair). These lesions present a post gadolinium multilayered ring enhancement pattern (B: T1 post gadolinium) and central core with restrition of water molecules diffusibility (C: DWI, D: ADC map).
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Fig2: Brain magnetic resonance imaging(MRI)on day 2. Showed multiple rounded expansive lesions in basal ganglia region predominantly on the left side and in subcortical right parietal region with prominent oedema, resulting in modelling of lateral ventricles, slight deviation of middle line to the right side and reduction of sulci dimensions (A: T2 flair). These lesions present a post gadolinium multilayered ring enhancement pattern (B: T1 post gadolinium) and central core with restrition of water molecules diffusibility (C: DWI, D: ADC map).

Mentions: After admission to the ICU, a transesophageal echocardiogram was performed and ruled out signs of endocarditis. Ophthalmology specialist consultation confirmed the absence of ocular involvement and chest-abdomen CT ruled out other possible foci. Brain magnetic resonance imaging (MRI) revealed multiple lesions involving basal ganglia bilaterally and subcortical right parietal white matter, with surrounding oedema, resulting in modelling of lateral ventricles, slight midline deviation and reduction of basal cisterns and sulci dimensions (Figure 2). These lesions were heterogeneous, some with multilayered signal differences and double-ring enhancement, and smaller ones presenting single layer ring enhancement in post gadolinium images. All lesions showed a core with restriction diffusibility to water molecules movement on diffusion weighted imaging (DWI, Figure 2). No haemorrhage was seen. These imagiological findings were consistent with brain abscesses, most probably fungal or pyogenic, the latter less likely due to the double-layer pattern enhancement. On day 2, empiric anti-fungal therapy with IV fluconazole 800 mg qd was added to the therapeutic regimen.Figure 2


Candida albicans brain abscesses in an injection drug user patient: a case report.

Neves N, Santos L, Reis C, Sarmento A - BMC Res Notes (2014)

Brain magnetic resonance imaging(MRI)on day 2. Showed multiple rounded expansive lesions in basal ganglia region predominantly on the left side and in subcortical right parietal region with prominent oedema, resulting in modelling of lateral ventricles, slight deviation of middle line to the right side and reduction of sulci dimensions (A: T2 flair). These lesions present a post gadolinium multilayered ring enhancement pattern (B: T1 post gadolinium) and central core with restrition of water molecules diffusibility (C: DWI, D: ADC map).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4255923&req=5

Fig2: Brain magnetic resonance imaging(MRI)on day 2. Showed multiple rounded expansive lesions in basal ganglia region predominantly on the left side and in subcortical right parietal region with prominent oedema, resulting in modelling of lateral ventricles, slight deviation of middle line to the right side and reduction of sulci dimensions (A: T2 flair). These lesions present a post gadolinium multilayered ring enhancement pattern (B: T1 post gadolinium) and central core with restrition of water molecules diffusibility (C: DWI, D: ADC map).
Mentions: After admission to the ICU, a transesophageal echocardiogram was performed and ruled out signs of endocarditis. Ophthalmology specialist consultation confirmed the absence of ocular involvement and chest-abdomen CT ruled out other possible foci. Brain magnetic resonance imaging (MRI) revealed multiple lesions involving basal ganglia bilaterally and subcortical right parietal white matter, with surrounding oedema, resulting in modelling of lateral ventricles, slight midline deviation and reduction of basal cisterns and sulci dimensions (Figure 2). These lesions were heterogeneous, some with multilayered signal differences and double-ring enhancement, and smaller ones presenting single layer ring enhancement in post gadolinium images. All lesions showed a core with restriction diffusibility to water molecules movement on diffusion weighted imaging (DWI, Figure 2). No haemorrhage was seen. These imagiological findings were consistent with brain abscesses, most probably fungal or pyogenic, the latter less likely due to the double-layer pattern enhancement. On day 2, empiric anti-fungal therapy with IV fluconazole 800 mg qd was added to the therapeutic regimen.Figure 2

Bottom Line: Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy.Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect.This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.

View Article: PubMed Central - PubMed

Affiliation: Infectious Diseases Department, Centro Hospitalar São João and Faculty of Medicine of Porto University, Porto, Portugal. nelianeves@gmail.com.

ABSTRACT

Background: Fungal brain abscess is an uncommon disease, mostly associated with immunocompromised states and poorly controlled diabetes. Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy. Candida species have emerged as the most prevalent etiologic agents of brain abscesses in autopsy studies.

Case presentation: A 46-year-old male with a history of injection drug abuse, chronic hepatitis C and diabetes mellitus presented to the Emergency Department of our hospital following a generalized tonic-clonic seizure without recovery of mental status. On admission, the patient was in coma, febrile, with severe acidemia with respiratory and metabolic acidosis, requiring invasive mechanical ventilation. Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect. Microbiologic studies, including cerebrospinal fluid, blood, sputum and urine cultures, were all negative. A stereotactic brain biopsy was performed and culture of brain specimens revealed Candida albicans. The patient was successfully treated with fluconazole therapy for 48 weeks presenting a good clinical response and a complete radiological resolution of brain abscesses.

Conclusion: Despite advances in diagnostic and therapeutic procedures, fungal brain abscess remains a life-threatening disease with a poor outcome. Successful treatment requires an early diagnosis and usually a combined medical and surgical approach. A long-term antibiotic regimen is a cornerstone of fungal brain abscesses treatment, with the endpoint determined by clinical and neuroimaging response. The authors report an uncommon case of successfully treated Candida albicans brain abscesses with anti-fungal therapy consisting of fluconazole alone. This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.

Show MeSH
Related in: MedlinePlus