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Invasive aspergillosis of the central nervous system in immunocompetent patients in Saudi Arabia: Case series and review of the literature

Mahmoud S. Taha, Mahmoud I. Haddad, Ali A. Almomen, Marwa M Abdulkader and Rami A. Alhazmi
Neurosciences Journal October 2021, 26 (4) 379-384; DOI: https://doi.org/10.17712/nsj.2021.4.20210081

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    - Axial enhanced brain computed tomography (CT) A) Axial enhanced brain computed tomography (CT) shows hyperdense opacification of the right frontal paranasal sinus with erosion of its posterior wall (black dashed arrow), B) Brain magnetic resonance imaging MRI scan Axial T2-weighted and, C) MRI T1-weighted post contrast show a large intra-axial lesion in the right frontal lobe with irregular thick peripheral enhancement (white arrows), D) MRI diffusion-weighted imaging shows no corresponding central diffusion restriction.

  • Figure 2
    Figure 2

    - Hematoxylin- and eosin-stained sections (magnification, 40x) showing A) neuroglial tissue containing ill-defined granulomata with multinucleated giant cells. Thin hyphae with regular septation and branching at a 45° angle are noted, B) Grocott’s methenamine silver stain demonstrating thin hyphae and spores (magnification, 20x).

  • Figure 3
    Figure 3

    - Detection methods for mycology: Specimens were inoculated on both selective fungal media (Mycosel, Becton, Dickenson and Company, MD, USA) and general fungal media Sabouraud Dextrose Agar (Titan Biotech Ltd, India) and incubated at 28°C–30°C for up to 4 weeks. Cultures with fungal growth were further worked up for mould identification using tease mount, scotch tape preparation and potato dextrose agar media for conidiation.The culture grew rapidly, producing a green–grey colony. The mould produced septate hyaline hyphae with smooth conidiophores supporting a dome-shaped vesicle. A row of phialides on the upper surface of the vesicle bore chains of round conidia in a columnar fashion characteristic of Aspergillus fumigatus.

  • Figure 4
    Figure 4

    - Axial plain brain CT shows (A) post-craniotomy changes in the right frontal aspect of the skull with haemorrhagic collection within the surgical bed (white arrow). Extensive ischemic low-attenuation tissue swelling in the right cerebral hemisphere and left frontal lobe is also observed (asterisks) along with a left-sided midline shift. (B) 3-dimensional reformatted MIP image from CTA shows occlusion of the right M1 segment (dashed arrow) and bilateral ACA (bidirectional arrow).

  • Figure 5
    Figure 5

    - Enhanced coronal brain CT shows a growing mass centred in the anterior skull base with bone erosions (arrows) along with intracranial, extra-axial and ethmoid sinus soft tissue components.

  • Figure 6
    Figure 6

    - Enhanced coronal brain CT on post-operative follow up does not show any evidence of recurrence.

Tables

  • Table 1

    - Summary of studies on IA of CNS in immunocompetent patients in Saudi Arabia including the current study.

    Study periodnAge: mean(range)Male/femaleAspergillus spp.Treatment anti-fungalClinical outcomeFollow up (months)
    Mohan et al7 (1987–92)442.2 (30–60)2/2A. flavus (4)Surgery/Amphotericin B3 no recurrence12-24 months
    1 death
    Ur-Rahman8 et al. (1983–94)947.3 (26–66)1/8A. flavus (6)Surgery/Amphotericin B plus flucytosine then itraconazole1 cured1-36 months
    6 residual or lost f/up
    A. fumigatus (3)
    2 death
    Baeesa et al9 (2000–12)1232 (17–50)4/8not definedSurgery/Amphotericin B plus itraconazole or variconazole8 cured12–50 months
    2 residual or recurrence
    2 deaths
    Taha et al (2012–18)333 (30–36)3/0not definedSurgery/Amphotericin B plus variconazole1 cured1-18 months
    2 deaths
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