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CNS Aspergillosis: Early Recognition Is Key
Imaging SESSION TITLE: Student/Resident Case Report Poster - Imaging SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
CNS Aspergillosis: Early Recognition Is Key Lydia Winnicka MD* Charumathi Raghu Subramanian MD Mayanka Kamboj MD; and Crystal Duran MD Guthrie Clinic, Sayre, PA INTRODUCTION: Invasive aspergillosis (IA) is a rare opportunistic infection that most commonly affects the immunocompromised. CNS Aspergillosis, a manifesation of IA, is a challenging diagnosis as symptoms are often non-specific. With a high case-fatality rate of 58%, a high index of suspicion is required.1 Knowing the various MRI manifestations of CNS Aspergillosis can help make a timely diagnosis. CASE PRESENTATION: A 62 year old female with Waldenstrom’s macroglobulinemia on carfilzomib, rituximab, and dexamethasone presented to the hospital after routine outpatient blood work revealed acute kidney injury. On admission, she had no complaints. Creatinine (Cr) was 2.8, white blood cell count was 1.8, and absolute neutrophil count (ANC) was 1530. Cycle 3 of chemotherapy was given on day 3 as per original schedule. ANC fell below 500 by day 5 and remained <500 for rest of hospitalization. Course was complicated by worsening Cr requiring hemodialysis on day 13. She also became newly confused on day 18. CT head on day 18 did not show any abnormality. CT chest showed bilateral upper lobe opacities and a 8.3 mm left upper lobe nodule. DWI sequences on MRI brain (day 19) showed bilateral foci of restricted diffusion in anterior and posterior circulation (Fig. 1). GRE images shows right frontal hemorrhage (Fig. 2). Due to unresponsiveness, she was intubated on day 20 and underwent bronchoscopy with bronchoalveolar lavage with final culture growing Aspergillus fumigatus. On day 25, as serum Aspergillus antigen came back positive at an index of 6.22 and serum (1,3)-beta-D-glucan came back positive at >500 pg/mL, voriconazole was started. Per her original wishes, as she did not improve, she was later made comfort care. DISCUSSION: This case illustrates the importance of recognizing MRI findings suspicious for CNS Aspergillosis. As a deep tissue biopsy is not realistic, characteristic MRI findings play an important role in diagnosis. Classically causing cerebral microhemorrhages, Aspergillus can also obstruct vessels and produce ischemic infarcts.2 Alternatively, Aspergillus can cause endocarditis and so embolic brain lesions.3 In our patient, in retrospect, MRI brain findings were suspicious for CNS Aspergillosis. CONCLUSIONS: The diagnosis of CNS Aspergillosis is challenging as symptoms are non-specific, invasive biopsies are not realistic, and confirmatory tests take time. This case illustrates that knowing various MRI brain manifestations of CNS Aspergillus can lead to a timely diagnosis in order to start therapy.
Reference #2: Ruhnke M, Kofla G, et al. CNS aspergillosis: recognition, diagnosis and management. CNS Drugs. 2007; 42 (10): 1417-1427. Reference #3: Starkey J, Moritani T, and Kirby P. MRI of CNS Fungal Infections: Review of Aspergillosis to Histoplasmosis and Everything in between. Clinical Neuroradiology. 2014; 24 (3): 217-230. DISCLOSURE: The following authors have nothing to disclose: Lydia Winnicka, Charumathi Raghu Subramanian, Mayanka Kamboj, Crystal Duran No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.761
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
667A
IMAGING
Reference #1: Lin S, Schranz J, and Teutsch S. Aspergillosis Case-Fatality Rate: Systematic Review of the Literature. Clinical Infectious Diseases. 2001; 32 (3): 358-66.
CNS Aspergillosis: Early Recognition Is Key Lydia Winnicka MD* Charumathi Raghu Subramanian MD Mayanka Kamboj MD; and Crystal Duran MD Guthrie Clinic, Sayre, PA INTRODUCTION: Invasive aspergillosis (IA) is a rare opportunistic infection that most commonly affects the immunocompromised. CNS Aspergillosis, a manifesation of IA, is a challenging diagnosis as symptoms are often non-specific. With a high case-fatality rate of 58%, a high index of suspicion is required.1 Knowing the various MRI manifestations of CNS Aspergillosis can help make a timely diagnosis. CASE PRESENTATION: A 62 year old female with Waldenstrom’s macroglobulinemia on carfilzomib, rituximab, and dexamethasone presented to the hospital after routine outpatient blood work revealed acute kidney injury. On admission, she had no complaints. Creatinine (Cr) was 2.8, white blood cell count was 1.8, and absolute neutrophil count (ANC) was 1530. Cycle 3 of chemotherapy was given on day 3 as per original schedule. ANC fell below 500 by day 5 and remained <500 for rest of hospitalization. Course was complicated by worsening Cr requiring hemodialysis on day 13. She also became newly confused on day 18. CT head on day 18 did not show any abnormality. CT chest showed bilateral upper lobe opacities and a 8.3 mm left upper lobe nodule. DWI sequences on MRI brain (day 19) showed bilateral foci of restricted diffusion in anterior and posterior circulation (Fig. 1). GRE images shows right frontal hemorrhage (Fig. 2). Due to unresponsiveness, she was intubated on day 20 and underwent bronchoscopy with bronchoalveolar lavage with final culture growing Aspergillus fumigatus. On day 25, as serum Aspergillus antigen came back positive at an index of 6.22 and serum (1,3)-beta-D-glucan came back positive at >500 pg/mL, voriconazole was started. Per her original wishes, as she did not improve, she was later made comfort care. DISCUSSION: This case illustrates the importance of recognizing MRI findings suspicious for CNS Aspergillosis. As a deep tissue biopsy is not realistic, characteristic MRI findings play an important role in diagnosis. Classically causing cerebral microhemorrhages, Aspergillus can also obstruct vessels and produce ischemic infarcts.2 Alternatively, Aspergillus can cause endocarditis and so embolic brain lesions.3 In our patient, in retrospect, MRI brain findings were suspicious for CNS Aspergillosis. CONCLUSIONS: The diagnosis of CNS Aspergillosis is challenging as symptoms are non-specific, invasive biopsies are not realistic, and confirmatory tests take time. This case illustrates that knowing various MRI brain manifestations of CNS Aspergillus can lead to a timely diagnosis in order to start therapy.
Reference #2: Ruhnke M, Kofla G, et al. CNS aspergillosis: recognition, diagnosis and management. CNS Drugs. 2007; 42 (10): 1417-1427. Reference #3: Starkey J, Moritani T, and Kirby P. MRI of CNS Fungal Infections: Review of Aspergillosis to Histoplasmosis and Everything in between. Clinical Neuroradiology. 2014; 24 (3): 217-230. DISCLOSURE: The following authors have nothing to disclose: Lydia Winnicka, Charumathi Raghu Subramanian, Mayanka Kamboj, Crystal Duran No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.761
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
667A
IMAGING
Reference #1: Lin S, Schranz J, and Teutsch S. Aspergillosis Case-Fatality Rate: Systematic Review of the Literature. Clinical Infectious Diseases. 2001; 32 (3): 358-66.