○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

ABSTRACT○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

INTRODUCTION

Aspergillosis of the central nervous sys-tem is an uncommon infection, mainly oc-curring in immunocompromised patients.There are various clinical presentation formsof this infection: aseptic1,2 and persistent men-ingitis, mycotic aneurysms,2 ischemic andhemorrhagic infarcts and the tumor-like formor aspergilloma. In this article we present acase of a patient with cerebral aspergilloma.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

CASE REPORT

A forty-two-year-old woman wasbrought to the emergency department. Shehad diabetes that was under poor controland she had been having progressive head-aches over a three-week period. Her mentalstate was impaired, and she had right-sidedbody weakness and loss of vision. The neu-rological examination showed right hemi-paresis, decreased visual acuity in the righteye and blindness in the left eye. There wasno eye deviation or anisocoria. Further ex-amination revealed comprehension aphasia,thus accounting for the impairment of hermental state.

A computed tomographic scan revealed atumor-like lesion with high density and mod-erate mass effect on the anterior left temporallobe with edema in the surrounding area. Itappeared to have moderate heterogeneousenhancement with iodide contrast solution.Magnetic resonance imaging showed also amass over the left temporal lobe in its mesialaspects and infiltrating the left cavernous si-nus, with a high signal in the T1-weighted

• Eberval Gadelha Figueiredo

• Erich Fonoff

• Marcos Gomes

• Emílio Macedo

• Raul Marino Júnior

Tumoral form of aspergillosisin central nervous system(cerebral aspergilloma):case reportDivision of Neurosurgical Clinic, Hospital das Clínicas, Faculdade deMedicina, Universidade de São Paulo, São Paulo, Brazil

Aspergillosis of the central nervous system is an un-common infection, mainly occurring in immuno-compromised patients. It may be presented inseveral forms: meningitis, mycotic aneurysms,infarcts and the tumoral form (aspergilloma). Theauthors report a case of a diabetic patient withcerebral aspergilloma.

KEY WORDS: Aspergillosis. Diabetes mellitus. As-pergillus. Central nervous system neoplasms.

series (Figure 1). The surrounding edema wasbest observed in the T2 series (Figure 2).

After compensating for her diabetes, sheunderwent surgery by means of temporopari-etal craniotomy. The lesion encountered had alight yellowish color, hard consistency and verysignificant bleeding when manipulated. Theintraoperative pathological examination revealedfungal hyphae. The operation became protractedand resection was only partially performed.

During the postoperative period, she wasgiven intravenous amphotericin B. She re-quired long treatment due to postoperativefungal meningitis that was probably elicitedby the surgical manipulation.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

DISCUSSION

Cerebral aspergillosis is an infrequentmedical condition, but it is still a potentiallyfatal disease. However, it has become morefrequently diagnosed because of high rates ofsuspicion among immunocompromised pa-tients such as those with transplants and HIV-positive or aids patients, who show higher in-cidence of the condition. In a series of 1,730transplanted patients, 60 were neurologicallycompromised and 18.3% of these hadaspergilloma.2 A few more cases with thetumoral form in immunocompromised pa-tients have been reported by Shuper.3

The lungs are probably the entry por-tal. However, isolated central nervous sys-tem aspergillosis (no detectable pulmonarydisease) has already been reported.4 Theprognosis in such patients is very poor evenwith surgical and anti-fungal treatment, es-pecially when there is an association with

Cas

e R

epor

t

Sao Paulo Med J 2003; 121(6):251-253.

São Paulo Medical Journal — Revista Paulista de Medicina252

Cas

e R

epor

tother bacteria or infections.1,4

Aspergilloma is even rarer in patients whoare apparently immunocompetent, althoughall cases described have had associated diseasessuch as diabetes mellitus or unhealthy habitslike drug abuse.1,4

Diagnosis of aspergilloma in immuno-competent patients remains difficult becausemedical staff rarely suspects this condition.

Figure 1. Coronal magnetic resonance imaging of the brain in the T1-weighted series after

gadolinium injection, showing a lesion over the left temporal lobe in its mesial aspect and

infiltrating the left cavernous sinus, with high signal.

Figure 2. Magnetic resonance imaging of the brain in the T2 series, showing left temporal

lobe edema.

Although such patients have much betterprognosis than for immunocompromisedpatients, the diagnosis is frequently missedor delayed.3

Neuroimaging gives some backing forconsidering such a diagnosis, although it doesnot bring any specific findings to light. Theradiological findings in aspergilloma cases arethe same as for brain abscesses and may have

an appearance similar to that of manytumors. There is frequently a ring-like en-hancement when contrast medium is in-jected. With magnetic resonance imaging, itappears as a tumoral lesion with a low signalin the T1-weighted series, with variableedema on the lesion periphery. Routineanalysis of cerebrospinal fluid does not helpin elucidating the etiology.

Sao Paulo Med J 2003; 121(6):251-253.

São Paulo Medical Journal — Revista Paulista de Medicina 253

Aspergiloma cerebral: Relato de caso

Aspergilose do sistema nervoso central é umainfecção rara, acometendo principalmente pa-cientes imunossuprimidos. Clinicamentepode se apresentar sob várias formas: menin-gite, aneurisma micótico, infartos cerebrais e

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

RESUMO

Eberval Gadelha Figueiredo, MD. Assistant neurosur-geon, Clinical Neurosurgery Division, Hospital das Clínicas,Faculdade de Medicina, Universidade de São Paulo, SãoPaulo, Brazil.

Erich Fonoff, MD. Resident doctor, Clinical NeurosurgeryDivision, Hospital das Clínicas, Faculdade de Medicina,Universidade de São Paulo, São Paulo, Brazil.

Marcos Gomes, MD. Assistant neurosurgeon, Clinical Neu-rosurgery Division, Hospital das Clínicas, Faculdade deMedicina, Universidade de São Paulo, São Paulo, Brazil.

Emílio Macedo, MD. Resident doctor, Clinical Neurosur-gery Division, Hospital das Clínicas, Faculdade deMedicina, Universidade de São Paulo, São Paulo, Brazil.

Raul Marino Júnior, MD. Professor, Clinical Neurosur-gery Division, Hospital das Clínicas, Faculdade deMedicina, Universidade de São Paulo, São Paulo, Brazil.

Sources of funding: None

Conflict of interest: None

Date of first submission: April 22, 2003

Last received: May 26, 2003

Accepted: May 30, 2003

Address for correspondence:Eberval Gadelha Figueiredo

3848, N 3rd AvenueApt. 3069Phoenix - Arizona 85013USAE-mail:ebergadelha@msn.com

COPYRIGHT © 2003, Associação Paulista de Medicina

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Publishing information

como lesão tumoral (aspergiloma). Os auto-res apresentam o caso de um paciente diabé-tico com aspergiloma cerebral.

PALAVRAS-CHAVE: Aspergilose. Diabetesmellitus. Aspergillus. Tumores cerebrais. Sis-tema nervoso central.

1. Boes B, Bashir R, Boes C, Hahn F, McConnell JR, McComb

R. Central nervous system aspergillosis. Analysis of 26 patients.

J Neuroimaging 1994;4(3):123-9.

2. Breneman E, Colford JM. Aspergillosis of the CNS pre-

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

REFERENCES

senting as aseptic meningitis. Clin Infect Dis 1992;

15(4):737-8.

3. Shuper A, Levitsky HI, Cornblath DR. Early invasive CNS as-

pergillosis. An easily missed diagnosis. Neuroradiology

1991;33(2):183-5.

4. Walsh TJ, Hier DB, Caplan LR. Aspergillosis of the central

nervous system: clinicopathological analysis of 17 patients. Ann

Neurol, 1985;18(5):574-82.

Sao Paulo Med J 2003; 121(6):251-253.