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CT and MR findings of brain aspergillosis
Computerized Medical Imaging and Graphics 27 (2003) 489–492 www.elsevier.com/locate/compmedimag
Short communication
CT and MR findings of brain aspergillosis Takashi Okafujia,*, Hidetake Yabuuchia, Yoshihisa Nagatoshib, Youichi Hattandac, Tatsuro Fukuyad a
Department of Radiology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan Department of Pediatrics, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan c Department of Pathology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan d Department of Radiology, National Oita Hospital, 2-11-45 Yokota, Oita 870-0263, Japan
b
Received 20 August 2002; accepted 11 February 2003
Abstract CT and MR findings of a case of brain aspergillosis with histopathologic correlation are reported. On both CT and MR images, there were multiple lesions in the corticomedullary junction (CMJ) that appeared to disrupt the cortical sulci and that were not enhanced by intravenous contrast material. In most of these lesions, there were centrally located structures that were enhanced by intravenous contrast material and that appeared to be continuous from markedly enhanced adjacent dilated cortical vessels. Histopathologic examination of the autopsy specimen showed multiple hemorrhagic infarcts in the CMJ with remaining dilated cortical vessels that had been thrombosed by aspergillus hyphae. q 2003 Elsevier Ltd. All rights reserved. Keywords: Aspergillosis; Immunocompromised; Brain, CT; Brain, MR
1. Introduction In immunosuppressed patients, aspergillus infection is invasive in nature and disseminates throughout the body. The brain is a common site of invasive aspergillosis hematogenously disseminated from an extracranial focus, most commonly from the lung [1]. Brain aspergillosis in an immunocompromised host has a poor prognosis, yet recent aggressive antifungal therapies have brought about more effective treatment [2,3]. Because of growing numbers of immunocompromised patients following extensive medical treatments such as bone marrow transplant (BMT), CT and MR are becoming more and more important in the early diagnosis of brain aspergillosis. CT and MR findings of brain aspergillosis have been reported in a number of studies [4 –12] which mention the following as characteristic findings of the disease: the involvement of both basal nuclei and the corticomedullary junction (CMJ), minimal or no contrast enhancement, * Corresponding author. Address: Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higash-ku, Fukuoka 812-8582, Japan. Tel.: þ 81-92-642-5695; fax: þ 8192-642-5708. E-mail address: [email protected] (T. Okafuji). 0895-6111/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0895-6111(03)00033-8
grossly hemorrhagic lesions, ring enhancement, and early vascular and meningeal enhancement. We here report a case of brain aspergillosis that showed multiple lesions in the CMJ with centrally located enhancement on CT and MR images, and we correlate these findings with the histopathologic findings of the autopsy specimen.
2. Case report The patient was an 11-year-old girl diagnosed with acute myelogenous leukemia who underwent allogenic BMT 3 months after the initial diagnosis. She suffered complications in the form of aspergillus pneumonia and was treated with fluconazole and amphotericin B for 3 months after BMT. Her serial chest radiographs showed improvement of the pneumonia, however, she suffered a sudden onset of epilepsy and loss of consciousness 160 days after the diagnosis of pulmonary aspergillosis was made and head CT and MR examinations were performed. Precontrast CT showed multiple hypodense lesions in the CMJ of the cerebrum and cerebellum. These lesions appeared to disrupt the cortical sulci and showed no enhancement following administration of the intravenous
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T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
Fig. 1. Axial plain CT image shows multiple hypodense lesions (arrows) in CMJ of the frontal and parietal lobe. At the center of some lesions, there is hyperdense dot or linear structure (arrowheads).
contrast material. In most of these lesions, there was a centrally located hyperdense structure (Fig. 1). These structures were minimally enhanced by intravenous contrast material, and appeared to be continuous from the dilated cortical vessels in the review of serial axial images. The lesions in the CMJ were hypointense on T1weighted MR images and hyperintense on T2-weighted MR images (Fig. 2(a) and (b)). In MR images, most lesions contained centrally located hyperintensity on T1-weighted images and hypointensity on T2-weighted images. These structures were minimally enhanced on post-contrast T1weighted images, and appeared to be continuous from dilated, markedly enhanced cortical veins (Fig. 2(c)). There was one grossly hemorrhagic lesion in the right temporal lobe, and a few cortical lesions with ring enhancement were found on both CT and MR images. The patient’s clinical status deteriorated rapidly and she died of systemic fungal infection on the same day as the onset of epilepsy. Macroscopic sections of autopsy specimens showed multiple necrotic lesions in the CMJ of the cerebrum and cerebellum (Fig. 3(a)). These lesions were noted on both sides of the cortical sulci where the cortical vessels are located (Fig. 3(b)); the cortical vessels, therefore, appeared to enter the central portion of the lesions in the CMJ. Petechial hemorrhages were found around the cortical vessels of these lesions. Microscopically, the lesions in the CMJ were determined to have resulted from hemorrhagic infarct with cerebritis. Dilated cortical arteries and veins that coursed between infarcted cortices were noted. Some vessels were thrombosed by aspergillus hyphae with vascular wall invasion.
Fig. 2. Axial MR images approximately the same level as Fig. 1. (a) T2weighted (TR/TE ¼ 4000/100), (b) T1-weighted (TR/TE ¼ 350/17), and (c) Gd-enhanced T1-weighted images. Lesions in the CMJ are hyperintense on T2-weighted image and hypointense on T1-weighted image (arrows). These lesions show central dot or linear structures that are hypointense on T2weighted image and minimally enhanced (small arrows) on Gd-enhanced T1weighted image. Note the dilated cortical vessels that are markedly enhanced.
3. Discussion Aspergillus is a ubiquitous saprophytic fungus, and infected patients with normal immunity most commonly present with inflammation of the paranasal sinus mucosa.
In immunosuppressed patients, however, aspergillus infection can be invasive in nature and disseminates throughout the body. The brain is a common site of invasive aspergillosis with an incidence of 10 –15% and is infected
T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
Fig. 3. (a) Coronal section of the cerebrum of the autopsy specimen. There is infarct (arrows) in CMJ of the right frontal lobe. The lesion is noted on both sides of the cortical sulci. (b) Low-power microscopic view of the same lesion (arrows) as a shows the hemorrhagic infarct with cerebritis. There are foci of petechial hemorrhage (small arrows). Dilated, thrombosed cortical arteries and veins (curved arrows) that course between infarcted cortex are noted. These vessels were thrombosed by aspergillus hyphae with vascular wall invasion on the high-power microscopic view.
by hematogenous dissemination from an extracranial focus that is commonly the lung [1] or by direct extension through the walls of the paranasal sinuses [4]. Brain aspergillosis in immunocompromised patients has a poor prognosis with a mortality rate approaching 85– 100%, and death usually occurs within 1 week of neurologic onset [5]; nevertheless, recent aggressive antifungal therapies have provided effective methods of treatment [2,3]. In the disseminated form of brain aspergillosis, aspergillus hyphae thrombose arteries and cause brain infarct that is commonly hemorrhagic. These sterile infarcts are readily converted to cerebritis or abscess by erosion of the arterial wall resulting in mycotic vasculitis and aneurysm [6]. This vasculitis-related septic infarction has an anatomic predilection for the CMJ due to the hematogenous route of dissemination of aspergillus hyphae as well as to the vascular anatomy of this interface. The involvement of the basal nuclei and thalami is also characteristic and indicates the involvement of the lenticulostriate and
491
thalamoperforator arteries. In addition, the corpus callosum is also a common site, which again reflects the predisposition of perforating arteries to aspergillosis. CT and MR findings of brain aspergillosis have previously been reported by a number of authors [4 – 12]. Ashdown et al. report three cross-sectional imaging patterns of brain aspergillosis: multiple cortical and subcortical areas of decreased CT attenuation or T2 hyperintensity corresponding to infarcts, multiple ring- or nodular-enhancing lesions, and dural enhancement adjacent to the paranasal sinus secondary to direct invasion of sinonasal disease [4]. These different imaging patterns have been reported to depend on the immune status of the patient [8]. In patients with severe immunosuppression, brain lesions have been reported to be consistent with acute infarct usually resulting in a rapid fatal outcome. On cross-sectional imaging, the lesion shows little or no mass effect, and there is minimal or no contrast enhancement that can be explained by the rapidity of evolution of the disease or by the absence of inflammatory response related to corticosteroid therapy [8]. In patients with less severe immunosuppression, brain lesions have been reported to show ring or nodular enhancement on contrast-enhanced T1-weighted MR images consistent with abscess or granuloma. This indicates that the host’s defence system is able to isolate or encapsulate the offending organism. These patients have an excellent prognosis for survival under aggressive antifungal treatment. In the case of our patient, the CT and MR findings as well as her clinical course were similar to those of patients with severe immunosuppression. In our patient, the cortical vessels were dilated and markedly enhanced on MR images. Dilated and grossly enhanced cortical vessels in brain aspergillosis have been reported by Van der Knaap et al. [9] who state that this enhancement was thought to indicate vascular and perivascular inflammation or thrombophlebitis. In our case, there were numerous aspergillus hyphae in the cortical vessels, and microscopic examination revealed that some vessels had been thrombosed by fungal invasion. We assume that dilatation and enhancement of the cortical vessels were consistent with aspergillus vasculopathy, and that the hypointensity on the patient’s T2-weighted MR images represented aspergillus hyphae, fresh thrombus in the vessels, and small foci of hemorrhage around the vessels. We also assume that hyperdensity on plain CT represents thrombus within the cortical vessels. Macroscopic sections revealed multiple infarcts in the CMJ of the cerebrum and cerebellum that were consistent with the CT and MR findings. These infarcts were observed on both sides of the cortical sulci; the cortical vessels, therefore, coursed in the central portion of these lesions in the CMJ. These cortical vessels appeared as a centrally located dot-like structure rather than a linear structure because they coursed perpendicular to the axial image in
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T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
most instances. These CT and MR findings reflect the angioinvasive nature of aspergillus, and can be used to diagnose this condition.
4. Summary We report here on CT and MR findings of brain aspergillosis with histopathologic correlation. Multiple lesions in the CMJ were consistent with infarct due to aspergillus vasculopathy. Of particular interest was the fact that dilated cortical vessels located in the central portion of the lesions were noted in lesions in the CMJ on both CT and MR images. This distinctive sign could be helpful in diagnosing brain aspergillosis.
[9] Knaap VD, Valk J, Janse GH, et al. Mycotic encephalitis: predilection for grey matter. Diagnostic Neuroradiol 1993;35:567 –72. [10] Enzmann DR, Brant-Zawadzki M, Britt RH. CT of central nervous system infections in immunocompromised patients. Am J Neuroradiol 1980;1:239–43. [11] Grossman RI, Davis KR, Taveras JM, et al. Computed tomography of intracranial aspergillosis. J Comput Assist Tomogr 1981;5:646–50. [12] Yuh WTC, Nguyen HD, Gao F, et al. Brain parenchymal infection in bone marrow transplantation patients: CT and MR findings. Am J Roentgenol 1994;12:425– 30.
Takashi Okafuji is a graduate student of Department of Clinical Radiology, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan, at present and was registered as a Radiologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan, from 1999 to 2000.
References [1] Torre CJ, Lopez OL, Kusne S, et al. CNS aspergillosis in organ transplantation: a clinicopathological study. J Neurol Neurosurg Psychiatry 1993;56:188 –93. [2] Khoury H, Adkins D, Miller G, et al. Resolution of invasive central nervous system aspergillosis in a transplant recipient. Bone Marrow Transplant 1997;20:179– 80. [3] Schwartz S, Milatovic D, Thiel E. Successful treatment of cerebral aspergillosis with a novel triazole (voriconazole) in a patient with acute leukemia. Br J Haematol 1997;97:663–5. [4] Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of the brain and paranasal sinusis in immunocompromised patients: CT and MR findings. Am J Roentgenol 1994;162:155–9. [5] Harris DE, Enterkine DS. Fungal infection of the central nervous system. Neuroimaging Clin N Am 1997;7:187–98. [6] Cox J, Murtagh FR, Wilfong A, et al. Cerebral aspergillosis: MR imaging and histopathologic correlation. Am J Neuroradiol 1992;13: 1489–92. [7] Miaux Y, Ribaud P, Williams M, et al. MR of cerebral aspergillosis in patients who have had bone marrow transplantation. Am J Neuroradiol 1995;16:555–62. [8] DeLone DR, Goldstein RA, Petermann G, et al. Disseminated aspergillosis involving the brain: distribution and imaging characteristics. Am J Neuroradiol 1999;20:1597–604.
Hidetake Yabuuchi is a Radiologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Yoshihisa Nagatoshi is a pediatrician at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Youichi Hattanda is a pathologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Tatsuro Fukuya is a Radiologist at National Oita Hospital, Department of Radiology, Oita, Japan.
Short communication
CT and MR findings of brain aspergillosis Takashi Okafujia,*, Hidetake Yabuuchia, Yoshihisa Nagatoshib, Youichi Hattandac, Tatsuro Fukuyad a
Department of Radiology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan Department of Pediatrics, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan c Department of Pathology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan d Department of Radiology, National Oita Hospital, 2-11-45 Yokota, Oita 870-0263, Japan
b
Received 20 August 2002; accepted 11 February 2003
Abstract CT and MR findings of a case of brain aspergillosis with histopathologic correlation are reported. On both CT and MR images, there were multiple lesions in the corticomedullary junction (CMJ) that appeared to disrupt the cortical sulci and that were not enhanced by intravenous contrast material. In most of these lesions, there were centrally located structures that were enhanced by intravenous contrast material and that appeared to be continuous from markedly enhanced adjacent dilated cortical vessels. Histopathologic examination of the autopsy specimen showed multiple hemorrhagic infarcts in the CMJ with remaining dilated cortical vessels that had been thrombosed by aspergillus hyphae. q 2003 Elsevier Ltd. All rights reserved. Keywords: Aspergillosis; Immunocompromised; Brain, CT; Brain, MR
1. Introduction In immunosuppressed patients, aspergillus infection is invasive in nature and disseminates throughout the body. The brain is a common site of invasive aspergillosis hematogenously disseminated from an extracranial focus, most commonly from the lung [1]. Brain aspergillosis in an immunocompromised host has a poor prognosis, yet recent aggressive antifungal therapies have brought about more effective treatment [2,3]. Because of growing numbers of immunocompromised patients following extensive medical treatments such as bone marrow transplant (BMT), CT and MR are becoming more and more important in the early diagnosis of brain aspergillosis. CT and MR findings of brain aspergillosis have been reported in a number of studies [4 –12] which mention the following as characteristic findings of the disease: the involvement of both basal nuclei and the corticomedullary junction (CMJ), minimal or no contrast enhancement, * Corresponding author. Address: Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higash-ku, Fukuoka 812-8582, Japan. Tel.: þ 81-92-642-5695; fax: þ 8192-642-5708. E-mail address: [email protected] (T. Okafuji). 0895-6111/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0895-6111(03)00033-8
grossly hemorrhagic lesions, ring enhancement, and early vascular and meningeal enhancement. We here report a case of brain aspergillosis that showed multiple lesions in the CMJ with centrally located enhancement on CT and MR images, and we correlate these findings with the histopathologic findings of the autopsy specimen.
2. Case report The patient was an 11-year-old girl diagnosed with acute myelogenous leukemia who underwent allogenic BMT 3 months after the initial diagnosis. She suffered complications in the form of aspergillus pneumonia and was treated with fluconazole and amphotericin B for 3 months after BMT. Her serial chest radiographs showed improvement of the pneumonia, however, she suffered a sudden onset of epilepsy and loss of consciousness 160 days after the diagnosis of pulmonary aspergillosis was made and head CT and MR examinations were performed. Precontrast CT showed multiple hypodense lesions in the CMJ of the cerebrum and cerebellum. These lesions appeared to disrupt the cortical sulci and showed no enhancement following administration of the intravenous
490
T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
Fig. 1. Axial plain CT image shows multiple hypodense lesions (arrows) in CMJ of the frontal and parietal lobe. At the center of some lesions, there is hyperdense dot or linear structure (arrowheads).
contrast material. In most of these lesions, there was a centrally located hyperdense structure (Fig. 1). These structures were minimally enhanced by intravenous contrast material, and appeared to be continuous from the dilated cortical vessels in the review of serial axial images. The lesions in the CMJ were hypointense on T1weighted MR images and hyperintense on T2-weighted MR images (Fig. 2(a) and (b)). In MR images, most lesions contained centrally located hyperintensity on T1-weighted images and hypointensity on T2-weighted images. These structures were minimally enhanced on post-contrast T1weighted images, and appeared to be continuous from dilated, markedly enhanced cortical veins (Fig. 2(c)). There was one grossly hemorrhagic lesion in the right temporal lobe, and a few cortical lesions with ring enhancement were found on both CT and MR images. The patient’s clinical status deteriorated rapidly and she died of systemic fungal infection on the same day as the onset of epilepsy. Macroscopic sections of autopsy specimens showed multiple necrotic lesions in the CMJ of the cerebrum and cerebellum (Fig. 3(a)). These lesions were noted on both sides of the cortical sulci where the cortical vessels are located (Fig. 3(b)); the cortical vessels, therefore, appeared to enter the central portion of the lesions in the CMJ. Petechial hemorrhages were found around the cortical vessels of these lesions. Microscopically, the lesions in the CMJ were determined to have resulted from hemorrhagic infarct with cerebritis. Dilated cortical arteries and veins that coursed between infarcted cortices were noted. Some vessels were thrombosed by aspergillus hyphae with vascular wall invasion.
Fig. 2. Axial MR images approximately the same level as Fig. 1. (a) T2weighted (TR/TE ¼ 4000/100), (b) T1-weighted (TR/TE ¼ 350/17), and (c) Gd-enhanced T1-weighted images. Lesions in the CMJ are hyperintense on T2-weighted image and hypointense on T1-weighted image (arrows). These lesions show central dot or linear structures that are hypointense on T2weighted image and minimally enhanced (small arrows) on Gd-enhanced T1weighted image. Note the dilated cortical vessels that are markedly enhanced.
3. Discussion Aspergillus is a ubiquitous saprophytic fungus, and infected patients with normal immunity most commonly present with inflammation of the paranasal sinus mucosa.
In immunosuppressed patients, however, aspergillus infection can be invasive in nature and disseminates throughout the body. The brain is a common site of invasive aspergillosis with an incidence of 10 –15% and is infected
T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
Fig. 3. (a) Coronal section of the cerebrum of the autopsy specimen. There is infarct (arrows) in CMJ of the right frontal lobe. The lesion is noted on both sides of the cortical sulci. (b) Low-power microscopic view of the same lesion (arrows) as a shows the hemorrhagic infarct with cerebritis. There are foci of petechial hemorrhage (small arrows). Dilated, thrombosed cortical arteries and veins (curved arrows) that course between infarcted cortex are noted. These vessels were thrombosed by aspergillus hyphae with vascular wall invasion on the high-power microscopic view.
by hematogenous dissemination from an extracranial focus that is commonly the lung [1] or by direct extension through the walls of the paranasal sinuses [4]. Brain aspergillosis in immunocompromised patients has a poor prognosis with a mortality rate approaching 85– 100%, and death usually occurs within 1 week of neurologic onset [5]; nevertheless, recent aggressive antifungal therapies have provided effective methods of treatment [2,3]. In the disseminated form of brain aspergillosis, aspergillus hyphae thrombose arteries and cause brain infarct that is commonly hemorrhagic. These sterile infarcts are readily converted to cerebritis or abscess by erosion of the arterial wall resulting in mycotic vasculitis and aneurysm [6]. This vasculitis-related septic infarction has an anatomic predilection for the CMJ due to the hematogenous route of dissemination of aspergillus hyphae as well as to the vascular anatomy of this interface. The involvement of the basal nuclei and thalami is also characteristic and indicates the involvement of the lenticulostriate and
491
thalamoperforator arteries. In addition, the corpus callosum is also a common site, which again reflects the predisposition of perforating arteries to aspergillosis. CT and MR findings of brain aspergillosis have previously been reported by a number of authors [4 – 12]. Ashdown et al. report three cross-sectional imaging patterns of brain aspergillosis: multiple cortical and subcortical areas of decreased CT attenuation or T2 hyperintensity corresponding to infarcts, multiple ring- or nodular-enhancing lesions, and dural enhancement adjacent to the paranasal sinus secondary to direct invasion of sinonasal disease [4]. These different imaging patterns have been reported to depend on the immune status of the patient [8]. In patients with severe immunosuppression, brain lesions have been reported to be consistent with acute infarct usually resulting in a rapid fatal outcome. On cross-sectional imaging, the lesion shows little or no mass effect, and there is minimal or no contrast enhancement that can be explained by the rapidity of evolution of the disease or by the absence of inflammatory response related to corticosteroid therapy [8]. In patients with less severe immunosuppression, brain lesions have been reported to show ring or nodular enhancement on contrast-enhanced T1-weighted MR images consistent with abscess or granuloma. This indicates that the host’s defence system is able to isolate or encapsulate the offending organism. These patients have an excellent prognosis for survival under aggressive antifungal treatment. In the case of our patient, the CT and MR findings as well as her clinical course were similar to those of patients with severe immunosuppression. In our patient, the cortical vessels were dilated and markedly enhanced on MR images. Dilated and grossly enhanced cortical vessels in brain aspergillosis have been reported by Van der Knaap et al. [9] who state that this enhancement was thought to indicate vascular and perivascular inflammation or thrombophlebitis. In our case, there were numerous aspergillus hyphae in the cortical vessels, and microscopic examination revealed that some vessels had been thrombosed by fungal invasion. We assume that dilatation and enhancement of the cortical vessels were consistent with aspergillus vasculopathy, and that the hypointensity on the patient’s T2-weighted MR images represented aspergillus hyphae, fresh thrombus in the vessels, and small foci of hemorrhage around the vessels. We also assume that hyperdensity on plain CT represents thrombus within the cortical vessels. Macroscopic sections revealed multiple infarcts in the CMJ of the cerebrum and cerebellum that were consistent with the CT and MR findings. These infarcts were observed on both sides of the cortical sulci; the cortical vessels, therefore, coursed in the central portion of these lesions in the CMJ. These cortical vessels appeared as a centrally located dot-like structure rather than a linear structure because they coursed perpendicular to the axial image in
492
T. Okafuji et al. / Computerized Medical Imaging and Graphics 27 (2003) 489–492
most instances. These CT and MR findings reflect the angioinvasive nature of aspergillus, and can be used to diagnose this condition.
4. Summary We report here on CT and MR findings of brain aspergillosis with histopathologic correlation. Multiple lesions in the CMJ were consistent with infarct due to aspergillus vasculopathy. Of particular interest was the fact that dilated cortical vessels located in the central portion of the lesions were noted in lesions in the CMJ on both CT and MR images. This distinctive sign could be helpful in diagnosing brain aspergillosis.
[9] Knaap VD, Valk J, Janse GH, et al. Mycotic encephalitis: predilection for grey matter. Diagnostic Neuroradiol 1993;35:567 –72. [10] Enzmann DR, Brant-Zawadzki M, Britt RH. CT of central nervous system infections in immunocompromised patients. Am J Neuroradiol 1980;1:239–43. [11] Grossman RI, Davis KR, Taveras JM, et al. Computed tomography of intracranial aspergillosis. J Comput Assist Tomogr 1981;5:646–50. [12] Yuh WTC, Nguyen HD, Gao F, et al. Brain parenchymal infection in bone marrow transplantation patients: CT and MR findings. Am J Roentgenol 1994;12:425– 30.
Takashi Okafuji is a graduate student of Department of Clinical Radiology, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan, at present and was registered as a Radiologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan, from 1999 to 2000.
References [1] Torre CJ, Lopez OL, Kusne S, et al. CNS aspergillosis in organ transplantation: a clinicopathological study. J Neurol Neurosurg Psychiatry 1993;56:188 –93. [2] Khoury H, Adkins D, Miller G, et al. Resolution of invasive central nervous system aspergillosis in a transplant recipient. Bone Marrow Transplant 1997;20:179– 80. [3] Schwartz S, Milatovic D, Thiel E. Successful treatment of cerebral aspergillosis with a novel triazole (voriconazole) in a patient with acute leukemia. Br J Haematol 1997;97:663–5. [4] Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of the brain and paranasal sinusis in immunocompromised patients: CT and MR findings. Am J Roentgenol 1994;162:155–9. [5] Harris DE, Enterkine DS. Fungal infection of the central nervous system. Neuroimaging Clin N Am 1997;7:187–98. [6] Cox J, Murtagh FR, Wilfong A, et al. Cerebral aspergillosis: MR imaging and histopathologic correlation. Am J Neuroradiol 1992;13: 1489–92. [7] Miaux Y, Ribaud P, Williams M, et al. MR of cerebral aspergillosis in patients who have had bone marrow transplantation. Am J Neuroradiol 1995;16:555–62. [8] DeLone DR, Goldstein RA, Petermann G, et al. Disseminated aspergillosis involving the brain: distribution and imaging characteristics. Am J Neuroradiol 1999;20:1597–604.
Hidetake Yabuuchi is a Radiologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Yoshihisa Nagatoshi is a pediatrician at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Youichi Hattanda is a pathologist at National Kyushu Cancer Center, Department of Radiology, Fukuoka, Japan.
Tatsuro Fukuya is a Radiologist at National Oita Hospital, Department of Radiology, Oita, Japan.