APFID

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Title : A 75 year-old male w/ dizziness and fever
Date : February 16, 2010
Contributed by

Eun Jeong Joo, M.D. Samsung Medical Center, Seoul, South Korea

Patient History
Age/Sex 75-year-old / man
Chief complaint dizziness and fever
Present illness

He visited Samsung medical center complaining of fever and dizziness. He has been diagnosed to have lung and brain abscess at the local hospital.

Past medical history

He had been treated with pulmonary tuberculosis a few years ago.

Physical examination

Fever was checked and breath sound was decreased at right upper lung field.

Initial laboratory findings

Neurologic examination Motor power of left lower leg decreased to level 3.

Radiologic findings
Hospital course

MRI finding showed cerebral multifocal abscess and his chest radiographic showed mass lesion with paratratchal and mediastinal lymphadenopathy suggesting lung cancer with multiple metastasis. To treat cerebral abscess, stereotatic drainage from cerebral abscess was performed but, culture wasn\'t attempted at that time and parenteral antibiotics with ceftriaxone and metronidazole were administed for 1 month. Fine-needle aspirates from mass-like lung lesion revealed no evidence of malignancy. Despite of antibiotic treatment, cerebral abscess and multiple lung nodules and consolidation progressed. Lung lesions were suspicious necrotic pneumonia rather than malignancy at follow-up chest CT Repetitive PCNA against necrotic mass was tried and pathology showed acute supprative inflammation without evidence of malignancy. Special stain for PAS, GMS and AFB was performed


 
Question - ID Case of the Week ( February 16, 2010 )
What do you think the most likely diagnosis is?
 
Correct Answer

Aspergillus species was observed on special stained specimen. He was diagnosed as cerebral and pulmonary invasive aspergillosis in immunocompetent host.

 
Review

Review of cerebral and pulmonary aspergillosis in an immunocompetent host

 

 Since 1st case report of cerebral aspergillosis in an immunocompetent host described in 1986, about 30 cases have been reported worldwide. Before the introduction of voriconazole, amphotericin B was treatment of choice in cerebral aspergillosis and most of patients died despite high dose amphotericin B administration with 90% mortality rate.

In 2004, successful treatment with voriconazole was introduced showing improving survival in ICU patients. Treatment with voriconazole for definite or probable CNS aspergillosis enhanced clinical outcomes and improved survival rate about 31%. Recently published IDSA guideline recommended voriconazole as primary treatment of choice in cerebral aspergillosis rather than other antifungal agents.

 For the definite diagnosis of cerebral aspergillosis, pathologic specimen should be obtained from brain tissue. As adjunctive diagnostic tools, both Galatomannan assay and chest CT provided effective diagnostic yield for an early diagnosis and preemptive treatment in immune-compromised hosts with IPA, especially neutropenic patients. However the role of Galactomannan assay has been rarely exploited for the diagnosis of invasive aspergillosis in immunocompetent host.

 Combination therapy with voriconazole and caspofungin was associated with reduced mortaliy in small population study. Further study with large population is promising for convincing evidence of combination treatment in patients with invasive aspergillosis. 

 


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