Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 55, Num. 3, 2007, pp. 310-311

Neurology India, Vol. 55, No. 3, July-September, 2007, pp. 310-311

Letter To Editor

An isolated non-dural-based cerebellar aspergilloma in an immunocompetent patient

Kulkarni Vaijayantee, Rajshekhar Vedantam, Mathews MaryS

Department of Neurological Sciences, Christian Medical College Hospital, Vellore

Correspondence Address: Departments of Neurological Sciences and *Microbiology, Christian Medical College Hospital, Vellore, India. E-mail: rajshekhar@cmcvellore.ac.in

Date of Acceptance: 18-May-2007

Code Number: ni07096

Sir,

Aspergillus infections in the posterior fossa are either extensions of lesions from the mastoid sinuses or part of multiple fungal masses in the brain. ^[1],[2] We report a case of non-dural-based isolated aspergilloma of the cerebellar vermis in an immunocompetent patient. To our knowledge there are only two previous reports of immunocompetent patients with an isolated non-dural-based aspergilloma of the cerebellum. ^[3],[4]

A healthy 23-year-old male presented with a one-month history of holo-cranial headache, vomiting and gait ataxia. Nine months earlier he had developed chronic fever with cough and mild wheezing. He was treated with steroids initially for one month, along with anti-tuberculous therapy for nine months with which his symptoms had rapidly resolved. General and systemic examination, including the ear, nose and paranasal sinsues was unremarkable. Neurological examination revealed bilateral papilloedema and cerebellar ataxia.

Enzyme-linked immunosorbent assay for human immunodeficiency virus (HIV) was negative. Chest radiograph showed resolved opacities in the left lower zone with prominent bronchial markings. Magnetic resonance imaging (MRI) of the brain showed a well-defined mass in the cerebellar vermis, iso/hypointense on T1 weighted images and enhancing with gadolinium injection [Figure - 1].

Considering the past history of tuberculosis and the radiological features, a diagnosis of tuberculoma was considered. The patient underwent posterior fossa craniectomy and biopsy of the lesion. Histopathological examination revealed a lesion composed of confluent granulomata. Smears from the tissue revealed dichotomously branching fungal hyphae, suggestive of Aspergillus spp. [Figure - 2]. The fungal culture grew Aspergillus flavus .

The patient was treated with intravenous amphotericin B and oral itraconazole. Computed tomography revealed no regression in lesion size after treatment with 1.5 g of amphotericin. He thus underwent total excision of the lesion, followed by treatment with 500mg more of amphotericin B in divided doses. In the postoperative period he developed hydrocephalus and a pseudomeningocele necessitating a ventriculo-peritoneal shunt. He required a shunt revision six months later. He was treated with oral itraconazole 200 mg twice a day for one year. One year later, at the time of follow-up, CT scan of the brain showed no recurrence of the mass. However, there was isolated dilatation of the fourth ventricle [Figure - 3] for which he refused therapy.

Of the two reported immunocompetent patients with an isolated cerebellar aspergilloma, one was an adult ^[3] and another was an infant (his immune status being debatable). ^[4] The source of infection in our patient is unclear. Though Aspergillus is known to reside in tuberculous cavities, the chest X-rays did not reveal cavitatory lesions or a fungal ball. The other possibility is that he suffered from a pulmonary aspergillus infection initially which was misdiagnosed as tuberculosis but this is unlikely as he recovered with antituberculous therapy.

Patients with isolated fungal granulomas of the brain may be subjected to prolonged anti-tuberculous therapy empirically, leading to delay in diagnosis and administration of antifungal treatment, resulting in a poor outcome. ^[1] A high index of suspicion is required to order fungal culture studies. Total excision of the mass followed by adequate antifungal therapy, as was undertaken in our case, is likely to result in a cure.

References

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