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Cerebellar granuloma caused by Aspergillus fumigatus: first report from India
TRANSACTIONSOF ‘ME ROYAL SXIETYOFTROPICAL MEDICINEAND HYGIENE (1995) 89,83-84
83
hemisphere, with dilatation of the third and lateral ventricles, consistent with cerebellar gramtloma which was considered to be probably tuberculous.
Cerebellar granuloma Aspergillus fumigatus: from India
caused by first report
Operativejindings
Mary S. Mathews’ and Mathew J. ChandyZ Departments of ‘Microbiology and Weurological Sciences, Christian Medical College and Hospital, Vellore 632004, Tamilnadu, South India Keywords:
Aspqillusjkmigutus, cerebellargranuloma,India
Isolated fungal infections of the central nervous system in immunocom tent persons are uncommon. They present as granuromatous lesions of the cerebrum involving the frontal, parasellar and temporal regions by direct extension following infection of the paranasal sinuses (HARAN & CHANDY, 1993). As erg&s spp. are the commonest aetiological agents 0P this condition in India
Figure. Fungal structures seen in the lesion after digestion with vesicles of AspergiUusspp.
Scalp and bone were normal. The surface of the cerebellum also appeared normal. The lesion was 1 cm below the surface as a hard, fibrous, non-vascular mass which could be cut only wnh knife and scissors. The medial portion was excised, leaving intact the portion extending laterally up to the posterior aspect of the petrous. There was no normal cerebellum visible between the mass and the petrous. Post-operative course
Following surgery the patient had an uneventful postoperative course. He was started immediately on a full course of intravenous amphotericin B (1.5 g in divided doses) and rifampicin 600 mg/d for 6 months. At discharge, the patient had mild cerebellar dysfunction on the left side with no meningeal sign or any other neurological deficit.
KOH:A, distorted
(BANERJEEet al., 1977); isolated lesions of the cerebellum are rare. We now report the first case in India of fungal granuloma of the cerebellum which was microbiologically confirmed. Case report
A 3 1 years old man presented to the outpatient department of the Christian Medical College Hospital in Vellore. South India, with intermittent holocranial headache, neck pain and vomiting of 5 months duration. He also complained of intermittent fever for 3 months and altered sensorium for 10 d followed by urinary incontinence since the morning. On examination he was afebrile. His pulse was SO/mm and blood pressure 170/70 mm Hg. There was no palpable lymph node. His Glasgow coma score was 15115. Higher functions were normal. Venous pulsations were not visualized on fundus examination. His gaze evoked nystagmus on looking to the left side. His lower cranial nerves were normal. There was no motor or sensory deficit. All reflexes were symmetrical. He had left-sided cerebellar signs. Although neck stiffness was present, Kernig’s sign was negative. All other systems appeared normal.
hyphae with cystic dilations and
B, Large alobose structures simulatina
Examination of the lesion
Direct microscopy of the tissue after digestion with 20% KOH showed numerous septate fungal hyphae. Characteristically, Aspergillus spp. have hyphal elements 4-5 pm broad showing dichotomous branching with the branches oriented in the same direction. The elements from this tissue, however, exhibited atypical features including short globose and distorted hyphae (Figure). There were also irregular cystic dilations about twice the usual breadth of Aspergillus hyphae. Culture
The biopsied tissue was inoculated into 2 sets of Sabouraud’s dextrose agar, with and without antibiotics, and incubated at 37°C and 28°C. All inoculated points showed fine mycelial growth the next day, indicabe of large numbers of funnal elements in the tissue. The colomss gradually er&ged and their centres developed green pigmentation. Microscopical examination revealed subglobose vesicles with a single row of sterigmata confined to the distal end of the vesicle. This picture is consistent with A. fumigatus. Histologically, the lesion showed granulomatous inflammation and fungal elements with septatehyphae.
Investigations
Discussion
Chest X-rav was normal. Haemoalobin was 15.4 a%. Total white blood cell count was 1l-600/mm3, with ieutroohils 89%. lvmnhocvtes 10% and monocvtes 1%. Sekm creatimne w& O-9 mg% and random plasma glucose 153 mg%. Computerized tomography scan showed an isodense mass with peripheral enhancement in the left cerebellar
Aspergillus spp. are among the most common saprophytic fungi in the environment. Their spores are readily isolated from soil, compost, building sites and air. Of the 600 known s ecies, the commonest involved in human diseaseis A. Pumigatus. Fungal infections of the brain which are not a result of dissemmated infection are uncommon (HARAN &
84 CHANDY, 1993). From 1981 to 1992 only 13 caseswere seen in our hospital, and all had lesions in the cerebral hemispheres. This patient had no evidence of any other primary focus. His occupation as a labourer in construction sites probably exposed him constantly to large numbers of Aspergillus spores. Cerebral aspergillosis has been described from this region of India by VENUGOPAL et al. (1977). However, cerebellar aspergillosis is rare: there are only 2 documented casesin the world literature. SALMON (1983) reported the first casefrom the UK in a 14 years old boy with no evidence of any underlying disease,immunodeficiency or aspergillosis; the causative organism was identified as A. jluvus. BJORKHOLM & ELGEFORS(1986) reported the second case in a 48 years old woman with alveolar proteinosis simulating a brain tumour. Our report is the first documented record of cerebellar aspergilloma from India. Granulomatous lesions in India are most often clinically considered to be tuberculous. The results of surgical and medical treatment of intracranial aspergillus granulomata are not bad. In a seriesof 13 patients, of whom 12 were followed for 6-48 months, only 3 died (HARAN & CHANDY, 1993). The management of these casesincluded radical excision of the intra-
cerebral mass followed by long-term therapy with amphotericin B (1.5-2 g in divided doses), rifampicin (600 mg for 6 months), or ketoconazole (1200 mg/d for 6 months). Flurocytosine has also been advocated. Prompt recognition of the fungal aetiology of such lesions could lead to early treatment and a better prognosis. References
Banerjee,A. K., Singh,M. S., Kak, V. K., Talwar, P. & Rout, D. (1977). Cerebral aspergillosis; report of 8 cases. Indian Journal of Pathology and Microbiology,
4,91-99.
Bjorkholm, B. & Elgefors,B. (1986).Cerebellaraspergilloma. Scandinavian.7ournaIof InfectiousDiseases, 18,375-378. Haran, R. P. & Chandy, M. J. (1993). Intracranial Aspergillus granuloma. BritishJournal of Neurosurgery, 7,383-388. Salmon, M. A. (1983). Asp&us of the cerebellum. Journal of the Royal Societyof Medicine, 76,611-613.
Venugopal,P. V., Venugopal,T. V., Thiruneelakantan, K.,
Subramanian, S. & Shetty, B. M. (1977). Cerebral aspergillosis: report of two cases.Sabouraudia, 15,225-230. Received 30 June 1994; revised 16 August 1994; accepted for publication I7 August I994
1Announcer-nentl The ‘Prince Lkopold’ Institute for Tropical Anhverp, Belgium
Medicine
The following courseswill be held at the Institute Survival analysis methods 3-S May 1995
A seminar by Professor Dr Y. Hochberg of the University of Tel-Aviv, Israel. Mt%hodesavancies en recherche epidtkziologique (Z&mecows intensif) 8-19 May 1995
(organized jointly with the Service de Statistique, Limburgs Universitair Centrum, Diepenbeek, Belgique). This course will be given in French. Cows d’epidkmiologie clinique 6-16June 1995
This course will be given in French Further information can be obtained from Professor Dr A. De Muynck, Institut voor Tropische Geneeskunde, Nationalestraat 155, B-2000 Antwerpen, Belgium; telephone +32 3-247.66.66; fax +32 3-216.14.31. L
83
hemisphere, with dilatation of the third and lateral ventricles, consistent with cerebellar gramtloma which was considered to be probably tuberculous.
Cerebellar granuloma Aspergillus fumigatus: from India
caused by first report
Operativejindings
Mary S. Mathews’ and Mathew J. ChandyZ Departments of ‘Microbiology and Weurological Sciences, Christian Medical College and Hospital, Vellore 632004, Tamilnadu, South India Keywords:
Aspqillusjkmigutus, cerebellargranuloma,India
Isolated fungal infections of the central nervous system in immunocom tent persons are uncommon. They present as granuromatous lesions of the cerebrum involving the frontal, parasellar and temporal regions by direct extension following infection of the paranasal sinuses (HARAN & CHANDY, 1993). As erg&s spp. are the commonest aetiological agents 0P this condition in India
Figure. Fungal structures seen in the lesion after digestion with vesicles of AspergiUusspp.
Scalp and bone were normal. The surface of the cerebellum also appeared normal. The lesion was 1 cm below the surface as a hard, fibrous, non-vascular mass which could be cut only wnh knife and scissors. The medial portion was excised, leaving intact the portion extending laterally up to the posterior aspect of the petrous. There was no normal cerebellum visible between the mass and the petrous. Post-operative course
Following surgery the patient had an uneventful postoperative course. He was started immediately on a full course of intravenous amphotericin B (1.5 g in divided doses) and rifampicin 600 mg/d for 6 months. At discharge, the patient had mild cerebellar dysfunction on the left side with no meningeal sign or any other neurological deficit.
KOH:A, distorted
(BANERJEEet al., 1977); isolated lesions of the cerebellum are rare. We now report the first case in India of fungal granuloma of the cerebellum which was microbiologically confirmed. Case report
A 3 1 years old man presented to the outpatient department of the Christian Medical College Hospital in Vellore. South India, with intermittent holocranial headache, neck pain and vomiting of 5 months duration. He also complained of intermittent fever for 3 months and altered sensorium for 10 d followed by urinary incontinence since the morning. On examination he was afebrile. His pulse was SO/mm and blood pressure 170/70 mm Hg. There was no palpable lymph node. His Glasgow coma score was 15115. Higher functions were normal. Venous pulsations were not visualized on fundus examination. His gaze evoked nystagmus on looking to the left side. His lower cranial nerves were normal. There was no motor or sensory deficit. All reflexes were symmetrical. He had left-sided cerebellar signs. Although neck stiffness was present, Kernig’s sign was negative. All other systems appeared normal.
hyphae with cystic dilations and
B, Large alobose structures simulatina
Examination of the lesion
Direct microscopy of the tissue after digestion with 20% KOH showed numerous septate fungal hyphae. Characteristically, Aspergillus spp. have hyphal elements 4-5 pm broad showing dichotomous branching with the branches oriented in the same direction. The elements from this tissue, however, exhibited atypical features including short globose and distorted hyphae (Figure). There were also irregular cystic dilations about twice the usual breadth of Aspergillus hyphae. Culture
The biopsied tissue was inoculated into 2 sets of Sabouraud’s dextrose agar, with and without antibiotics, and incubated at 37°C and 28°C. All inoculated points showed fine mycelial growth the next day, indicabe of large numbers of funnal elements in the tissue. The colomss gradually er&ged and their centres developed green pigmentation. Microscopical examination revealed subglobose vesicles with a single row of sterigmata confined to the distal end of the vesicle. This picture is consistent with A. fumigatus. Histologically, the lesion showed granulomatous inflammation and fungal elements with septatehyphae.
Investigations
Discussion
Chest X-rav was normal. Haemoalobin was 15.4 a%. Total white blood cell count was 1l-600/mm3, with ieutroohils 89%. lvmnhocvtes 10% and monocvtes 1%. Sekm creatimne w& O-9 mg% and random plasma glucose 153 mg%. Computerized tomography scan showed an isodense mass with peripheral enhancement in the left cerebellar
Aspergillus spp. are among the most common saprophytic fungi in the environment. Their spores are readily isolated from soil, compost, building sites and air. Of the 600 known s ecies, the commonest involved in human diseaseis A. Pumigatus. Fungal infections of the brain which are not a result of dissemmated infection are uncommon (HARAN &
84 CHANDY, 1993). From 1981 to 1992 only 13 caseswere seen in our hospital, and all had lesions in the cerebral hemispheres. This patient had no evidence of any other primary focus. His occupation as a labourer in construction sites probably exposed him constantly to large numbers of Aspergillus spores. Cerebral aspergillosis has been described from this region of India by VENUGOPAL et al. (1977). However, cerebellar aspergillosis is rare: there are only 2 documented casesin the world literature. SALMON (1983) reported the first casefrom the UK in a 14 years old boy with no evidence of any underlying disease,immunodeficiency or aspergillosis; the causative organism was identified as A. jluvus. BJORKHOLM & ELGEFORS(1986) reported the second case in a 48 years old woman with alveolar proteinosis simulating a brain tumour. Our report is the first documented record of cerebellar aspergilloma from India. Granulomatous lesions in India are most often clinically considered to be tuberculous. The results of surgical and medical treatment of intracranial aspergillus granulomata are not bad. In a seriesof 13 patients, of whom 12 were followed for 6-48 months, only 3 died (HARAN & CHANDY, 1993). The management of these casesincluded radical excision of the intra-
cerebral mass followed by long-term therapy with amphotericin B (1.5-2 g in divided doses), rifampicin (600 mg for 6 months), or ketoconazole (1200 mg/d for 6 months). Flurocytosine has also been advocated. Prompt recognition of the fungal aetiology of such lesions could lead to early treatment and a better prognosis. References
Banerjee,A. K., Singh,M. S., Kak, V. K., Talwar, P. & Rout, D. (1977). Cerebral aspergillosis; report of 8 cases. Indian Journal of Pathology and Microbiology,
4,91-99.
Bjorkholm, B. & Elgefors,B. (1986).Cerebellaraspergilloma. Scandinavian.7ournaIof InfectiousDiseases, 18,375-378. Haran, R. P. & Chandy, M. J. (1993). Intracranial Aspergillus granuloma. BritishJournal of Neurosurgery, 7,383-388. Salmon, M. A. (1983). Asp&us of the cerebellum. Journal of the Royal Societyof Medicine, 76,611-613.
Venugopal,P. V., Venugopal,T. V., Thiruneelakantan, K.,
Subramanian, S. & Shetty, B. M. (1977). Cerebral aspergillosis: report of two cases.Sabouraudia, 15,225-230. Received 30 June 1994; revised 16 August 1994; accepted for publication I7 August I994
1Announcer-nentl The ‘Prince Lkopold’ Institute for Tropical Anhverp, Belgium
Medicine
The following courseswill be held at the Institute Survival analysis methods 3-S May 1995
A seminar by Professor Dr Y. Hochberg of the University of Tel-Aviv, Israel. Mt%hodesavancies en recherche epidtkziologique (Z&mecows intensif) 8-19 May 1995
(organized jointly with the Service de Statistique, Limburgs Universitair Centrum, Diepenbeek, Belgique). This course will be given in French. Cows d’epidkmiologie clinique 6-16June 1995
This course will be given in French Further information can be obtained from Professor Dr A. De Muynck, Institut voor Tropische Geneeskunde, Nationalestraat 155, B-2000 Antwerpen, Belgium; telephone +32 3-247.66.66; fax +32 3-216.14.31. L