aspergilus flavus brain abscess

8/13/2019 Aspergilus Flavus Brain Abscess

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Am. J. Trop. Med. Hyg.,81(4), 2009, pp. 583586doi:10.4269/ajtmh.2009.09-0160Copyright 2009 by The American Society of Tropical Medicine and Hygiene

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* Address correspondence to Sophie Brun, Laboratoire deParasitologie-Mycologie, Groupe Hospitalier Piti-Salptrire, 47-83Boulevard de lHpital, 75651 Paris Cedex 13, France. E-mail: [email protected]

Case Report:Aspergillus flavusBrain Abscesses Associated with Hepatic Amebiasis

in a Non-neutropenic Man in Senegal

Sophie Brun,* Arnaud Fekkar, Antoine Busse, Danielle Seilhean, Marylin Lecs, Dan Adler, Hlne Prodanovic,Dominique Mazier, and Annick Datry

Laboratoire de Parasitologie-Mycologie, Laboratoire de Neuro-Pathologie, Laboratoire de Bactriologie-Hygine, et Pneumologie et Unit de Soins

Intensifs, Universit Pierre et Marie Curie-Paris 6, Assistance Publique-Hpitaux de Paris, Groupe Hospitalier Piti-Salptrire, Paris, France

Abstract. A non-neutropenic man living in Senegal was repatriated to France for liver amebic abscesses associatedwith brain abscesses presumed to be of amebic origin. Surprisingly, the post-mortem examinations of brain abscessesshowedAspergillus flavus. The route of infection byA. flavusin this particular context is discussed.

INTRODUCTION

In an apparently immunocompetent man repatriated toFrance from Senegal for hepatic amebiasis associated withcerebral abscesses, the most likely diagnosis was diffusionof amebae to the brain. Unfortunately, in the case we report,the patient died eight days after his arrival in France despitean adapted treatment against visceral amebiasis. His necroticand hemorrhagic cerebral lesions increased and diffused intoalmost the entire brain unti l a temporal engagement occurred.Post-mortem examination of brain abscesses showed the pres-ence of Aspergillus flavus but not Entamoeba histolytica.Cerebral abscesses caused byAspergillusspecies are observedmostly in immunosuppressed patients. The most frequentincriminated species is A. fumigatus. In immunocompetentpersons, brain aspergillosis is most often of nasal and parana-sal origin and the most frequent species encountered isA. fla-vus. In this report,A. flavuswas responsible for brain abscessesin an apparently immunocompetent man who was not neutro-penic or lymphopenic, had not received corticosteroids, anddid not show paranasal sinus involvement. The route of infec-tion byA. flavusin this particular context is discussed.

CASE REPORT

A 56-year-old man from France who had an unremarkablemedical history and had lived in Senegal on a sailboat for fourmonths was repatriated from Dakar to France after being diag-nosed with multiple hepatic and cerebral amebic abscesses.He has been hospitalized 12 days before in the intensive careunit of a general hospital in Dakar for abdominal pain anddiarrhea with bloody mucus. He showed clinical hepatomeg-aly and multiple liver abscesses documented by ultrasonogra-phy. He was treated intravenously with metronidazole (500 mgthree times a day), ciprofloxacin (500 mg twice a day), and

ampicillin (2 g three times a day) in addition to receivingrehydratation.

Relevant laboratory data showed a leukocyte count of 15 109cells/L, a platelet count of 8.8 109cells/L, negative resultsfor malaria on a thick blood smear, negative results for anti-bodies against human immunodeficiency virus, and positiveserologic results for amebiasis. Ten days later, confusion asso-ciated with temporospatial disorientation developed in the

patient. A cerebral computed tomography (CT) scan showedthree low-density sustentorial lesions with a discreet perifocaledema. An abdominal CT scan showed three low-density focalhepatic lesions associated with perihepatic, perisplenic, andright pleural effusions. New laboratory values demonstrated a10-fold increase in transaminase and alkaline phosphatase lev-els associated with a prothrombin time of 32 seconds.

On his arrival at the Emergency Department of GroupeHospitalier Piti-Salptrire, Paris, on December 30, 2007, thepatient had stable neurologic, hemodynamic, and respiratoryfunctions. A CT scan of the brain showed a large abscess inthe left parieto-occipital region and two abscesses in the righttemporo-occipital region with perifocal edema but withoutmass effect. An abundant right pleural effusion without pleu-ral or parenchymatous lesion was noted on a chest CT, andan abdominal CT showed three voluminous hepatic abscesseswith transdiaphragmatic rupture. Because rapid hemodynamicdeterioration developed in the patient, he was transferred inthe intensive care unit where intubation, fluid resuscitation,catecholamine treatment, and pleural drainage were initiated.Treatment with metronidazole and ampicillin was continued.

The next day, because of severe anemia after an episode ofmelena, an emergency laparotomy was performed. A perforat-ing duodenal ulcer was found and sutured. Cholecystectomy,peritoneal wash, and samples from hepatic abscesses and peri-toneal liquid were obtained for analyses.

Among microbiologic findings, Escherichia coli and Kleb-siella sp. with extended-spectrum -lactamases and numer-ous colonies of Candida albicanswere recovered from hepaticand peritoneal samples. Bacteriologic cultures were preparedon sheep blood agar incubated under aerobic and anaerobicconditions, on chocolate agar supplemented with PolyViteX(bioMrieux, Marcy lEtoile, France) incubated in a 5% CO

2-

air incubator, and in brain-heart infusion medium. Productionof extended spectrum -lactamase was demonstrated by the

double-disk test. Fungal cultures were prepared in Sabouraudagar tubes with and without cycloheximide and incubated at37C.

Parasites were not found in pleural and peritoneal liquidsby direct examination. However, genic amplification of smallsubunit ribosomal DNA of Entamoeba histolytica by a con-ventional polymerase chain reaction (PCR) showed a posi-tive result.1 Results of serologic analysis for amebiasis werepositive but parasitologic examination of stool was not per-formed. In addition, results of multiple bacteriologic and fun-gal blood cultures were negative. Thin and thick blood smearswere negative for Plasmodiumspp. Therefore, treatment withmetronidazole was continued and the patient was then treated


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intravenously with imipenem (1 g four times a day), amikacin(1,250 mg once a day), and fluconazole (400 mg once a day).

The respiratory, hemodynamic, and infectious status of thepatient improved, but his neurologic functions began to dete-riorate on January 3 with progressive disappearance of brain-

stem reflexes. Magnetic resonance imaging (MRI) of the brainshowed augmentation of lesions with voluminous necrotic andhemorrhagic areas prevailing in occipital regions associatedwith radiologic signs of intracranial hypertension (Figure 1).Two days later, a repeat cranial CT scan showed augmenta-tion of lesions and perifocal edema associated with temporalengagement. In view of these extensive necrotic and diffuselesions, he was considered inoperable and when he showedclinical signs of cerebral death, it was decided to stop resusci-tation maneuvers. The patient died on January 7.

An autopsy was performed 36 hours after death and mac-roscopic examination showed a brain liquefied by multipleabscesses, pulmonary edema with green foam, multiple con-fluent hepatic abscesses, peritonitis, and pancreatic necrosis.

Histologic examination of the liver showed mutilating fibro-sis surrounding necrotic areas, but peripheral hepatic regionswere devoid of fibrosis, which suggested no underlying livercirrhosis. In addition, results of conventional PCR for E. his-tolytica in a hepatic abscess were positive. Histologic exam-ination of cerebral necrotic areas showed abscesses withpolynuclear infiltrates and diffuse vascular lesions with fibri-noid necrosis, thrombosis, and perivascular infarction. Resultsof a conventional PCR for E. histolyticain brain abscess andcerebrospinal fluid were negative.

In abscessed cerebral regions, periodic acidSchiff andGrocott methanamin silver (GMS) staining showed some sep-tated hyphae with acute angle branching suggestive of thegenus Aspergillus (Figure 2). This finding was confirmed by

Giemsa and GMS staining of brain abscesses and cerebro-spinal fluid, which showed fungal septated hyphae, and bycultures of cerebrospinal fluid on Sabouraud dextrose agar,which yielded five colonies ofA. flavusthat were easily identi-fied by macroscopic aspects and morphology by microscopicexamination. Brain abscesses likely remained sterile becausethe fungus was not viable when the autopsy was performed.Antifungal in vitrosusceptibility was not determined becauseof the death of the patient.

To support these results, a TaqMan-based real-time PCR wasconducted with DNA extracted from cerebral abscesses, cere-brospinal fluid, and pulmonary fragment (the fragment was pre-served in formaldehyde) from the post-mortem examination

and from pleural fluid obtained on December 30. This assay wasspecific for mitochondrial DNA ofA. fumigatus.2 The PCR,which was validated in our laboratory with pulmonary tissuesfrom mice and was only genus specific, yielded PCR productsexclusive for both cerebral samples. A retrospective search for

galactomannan antigen (PlateliaAspergillus

; Bio-Rad, Marnes-la-Coquette, France) in a serum specimen obtained on January 2showed an index of 0.4, which is considered negative but it closeto the cutoff value of 0.5, and serologic results for the genus

Aspergillus by coelectrosyneresis with A. fumigatus antigen(Bio-Rad) were negative. Periodic acidSchiff and GMS stain-ing of numerous lung specimens did not show fungal hyphae.

DISCUSSION

Invasive aspergillosis occurs mostly in immunosuppressedpatients. However, in recent years, there has been a signifi-cant increase in Aspergillus infections in immunocompetenthosts in which a number of extrapulmonary infections have

been observed, including central nervous system aspergillo-sis.3 Neuroaspergillosis is an uncommon infection account-ing for 5% of all cranial infections but it is associated withan exceedingly high mortality rate that approaches 100%. Inmost cases, diagnosis is made after death or at the terminal

Figure 1. Brain magnetic resonance imaging of the patient on January 3, 2008. A, Axial T2-weighted images showing voluminous and multiplenecrotico-hemorrhagic hyper-intense lesions associated with diffuse edema and mass effect.B, T1-weighted image of the left parieto-occipital local-ization showing spontaneous hyper-intensity demonstrating an associated hemorrhagic component.

Figure 2. Post-mortem Grocott methanamin silver staining of abrain abscess of the patient 36 hours after his death showing septatedhyphae with acute angle branching, which are suggestive of the genus

Aspergillus. Magnification 400. This figure appears in color at www.ajtmh.org.


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stage of disease. This disease is caused by an opportunistic fun-gal infection that usually affects heavily immunocompromisedhosts, typically patients with hematologic malignancy or bonemarrow or solid organ transplantation in whom neutropeniaand corticosteroid use are the major risks factors. Cerebralinvolvement commonly occurs by direct extension of invasive

Aspergillussinusitis or hematogenous spread from an occult

source, usually the lungs.4

In immunocompetent patients, thedisease has been described mostly in the setting of allergic rhi-nosinusitis caused byAspergillus species after neurosurgicalprocedures, and in patients with significant comorbidities suchas diabetes mellitus, severe malnutrition, or liver cirrhosis.5,6

Aspergillus fumigatusis the most frequently reported speciesin immunosuppressed hosts, but A. flavus has been isolatedmostly from immunocompetent patients.Aspergillus flavusisthe most common species isolated from cultures of nasal andparanasal specimens from immunocompetent patients withcerebral aspergillosis who do not have any risk factors butwho live in hot and dry countries.68

Aspergillus flavushas a worldwide distribution with an opti-mal growth temperature of 37C. However, fungal growth can

be observed at temperatures ranging from 12C to 48C.9

Thefungus is a soil saprophyte that plays an important role as anutrient recycler and is able to cause diseases in economicallyimportant crops such as maize and peanuts. Climatic condi-tions markedly influence the prevalence ofA. flavusin the air.It is particularly prevalent in the air of some tropical coun-tries with a dry and hot climate. In two studies in Iran, it wasthe most prevalent Aspergillus species isolated from the airof hospital wards and homes.9In addition, surveys of fungi indrinking water have isolated many different taxa, including

A. flavus, from water storage tanks.10To our knowledge, E. histolyticaandAspergillusspp. infec-

tions have never been reported concomitantly. We describe anapparently immunocompetent man (he was not neutropenic

or lymphopenic and did take any corticosteroids) who livedin Senegal and was repatriated to France for hepatic amebicabscesses associated with cerebral abscesses. These abscesseswere presumably to be of amebic origin, but were eventuallydetermined to be of fungal origin. Post-mortem examinationsof brain abscesses and cerebrospinal fluid by histologic andmycologic staining showed fungal septated hyphae, five colo-nies ofA. flavusisolated in cultures from cerebrospinal fluid,and positive genomic amplification ofAspergillusspp. by real-time PCR.

Our findings were surprising in an apparently immunocom-petent man and in the context of liver amebiasis. Moreover,distinction between E. histolyticaandAspergillusspp. in cere-bral abscesses is not easy because radioimaging features are

not specific, and frequent ring-like enhancing lesions for bothinfections and other multiple patterns can be observed, espe-cially in cerebral aspergillosis.11However, E. histolyticawas notidentified by PCR in cerebrospinal fluid and brain abscesses.In addition, identification of hyaline, septated hyphae withdichotomous branching by histologic and mycologic stainingof cerebrospinal fluid and brain abscesses, and isolation of five

A. flavus colonies from cerebrospinal fluid culture implicateA. flavusas the causative agent of brain aspergillosis in thispatient and exclude the possibility of sample contamination atthe time of the autopsy. The negative result forAspergillusspp.galactomannan antigen in serum does not exclude the diagno-sis of invasive aspergillosis because this assay has a sensitivity

of 97.4% for neutropenic patients. However, this assay has notbeen tested in immunocompetent patients.12

The route of infection in our patient is unclear and no othersites of aspergillosis were detected. The patient had no evi-dence of sinus disease by CT scan and MRI, and the locationof the cerebral abscesses did not suggest nasal or paranasalorigin. Moreover, because a few reports described invasive

pulmonary aspergillosis in immunocompetent patients,3

wesearched for evidence to support this hypothesis. However, ourpatient had no evidence of invasive pulmonary aspergillosis byCT scan and histologic post-mortem examinations of the lungs.Galactomannan antigen was not detected in serum (broncho-alveolar lavage was not performed). In addition, his neutrophiland lymphocyte counts were normal; serologic results for anti-bodies against human immunodeficiency virus were negative;and factors predisposing the patient to invasive aspergillosissuch as diabetes mellitus, steroid exposure, liver cirrhosis, intra-venous drug abuse, or head trauma were not observed.

The digestive tract may have been a portal of entry forA. flavusin this patient. This route of invasive aspergillosis hasbeen described in a few severely immunosuppressed patients,

all with peritonitis, but never demonstrated.13,14

Aspergillusflavus is noted for causing crop disease in tropical countriesand has been isolated from water, but the fungus was not iso-lated from peritoneal fluid from our patient who was not neu-tropenic or lymphopenic. Moreover, septated hyphae were notfound in samples of digestive tract (stomach, ileum, and colon)that were examined.

In conclusion, we report a case of cerebral abscesses causedby A. flavusthat led to the death of a non-neutropenic manwho lived in Senegal and was repatriated to France for ame-bic liver abscesses associated with brain abscesses presumablyof amebic origin. This case highlights the diagnostic challengepresented by central nervous system aspergillosis in non-neu-tropenic patients and underscores its grave prognosis. Of note

is the species ofAspergillusinvolved,A. flavus, which is knownto be more prevalent in immunocompetent patients and in hotand dry countries.

Received March 24, 2009. Accepted for publication June 16, 2009.

Authors addresses: Sophie Brun, Arnaud Fekkar, Antoine Busse,Dominique Mazier, and Annick Datry, Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Piti-Salptrire, 4783 Boulevardde lHpital, 75651 Paris Cedex 13, France, E-mail: [email protected]. Danielle Seilhean, Laboratoire de Neuro-Pathologie, GroupeHospitalier Piti-Salptrire, Paris, France. Marylin Lecs, Laboratoirede Bactriologie-Hygine, Groupe Hospitalier Piti-Salptrire, Paris,France. Dan Adler and Hlne Prodanovic, Pneumologie et Unit deSoins Intensifs, Groupe Hospitalier Piti-Salptrire, Paris, France.

Reprint requests: Sophie Brun, Laboratoire de Parasitologie-

Mycologie, Groupe Hospitalier Piti-Salptrire, 4783 Boulevardde lHpital, 75651 Paris Cedex 13, France, E-mail: [email protected].

REFERENCES

1. Acuna-Soto R, Samuelson J, De Girolami P, Zarate L, Millan-Velasco F, Schoolnick G, Wirth D, 1993. Application of the poly-merase chain reaction to the epidemiology of pathogenic andnonpathogenic Entamoeba histolytica. Am J Trop Med Hyg 48:5870.

2. Costa C, Vidaud D, Olivi M, Bart-Delabesse E, Vidaud M, BretagneS, 2001. Development of two real-time quantitative TaqManPCR assays to detect circulatingAspergillus fumigatusDNA inserum.J Microbiol Methods 44:263269.


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3. Paterson DL, 2004. New clinical presentations of invasive asper-gillosis in non-conventional hosts. Clin Microbiol Infect 10(Suppl 1):2430.

4. Patterson TF, Kirkpatrick WR, White M, Hiemenz JW, WingardJR, Dupont B, Rinaldi MG, Stevens DA, Graybill JR, 2000.Invasive aspergillosis. Disease, spectrum, treatment practices,and outcomes. I3AspergillusStudy Group.Medicine (Baltimore)79:250260.

5. Kim DG, Hong SC, Kim HJ, Chi JG, Han MH, Choi KS, Han DH,

1993. Cerebral aspergillosis in immunologically competentpatients. Surg Neurol 40:326331.

6. Siddiqui AA, Shah AA, Bashir SH, 2004. Craniocerebral aspergil-losis of sinonasal origin in immunocompetent patients:clinical spectrum and outcome in 25 cases. Neurosurgery 55:602611.

7. Alrajhi AA, Enani M, Mahasin Z, Al-Omran K, 2001. Chronicinvasive aspergillosis of the paranasal sinuses in immunocom-petent hosts from Saudi Arabia. Am J Trop Med Hyg 65:8386.

8. Yagi HI, Gumma SA, Shumo AI, Abdalla N, Gadir AA, 1999.Nasosinus aspergillosis in Sudanese patients: clinical features,pathology, diagnosis, and treatment.J Otolaryngol 28:9094.

9. Hedayati MT, Pasqualotto AC, Warn PA, Bowyer P, Denning DW,2007.Aspergillus flavus: human pathogen, allergen and myco-toxin producer. Microbiology 153:16771692.

10. Anaissie EJ, Stratton SL, Dignani MC, Summerbell RC, Rex JH,Monson TP, Spencer T, Kasai M, Francesconi A, Walsh TJ, 2002.PathogenicAspergillusspecies recovered from hospital watersystem: a 3-year prospective study. Clin Infect Dis 34:780789.

11. Phuttharak W, Hesselink JR, Wixom C, 2005. MR features of cere-bral aspergillosis in an immunocompetent patient: correlation

with histology and elemental analysis.AJNR Am J Neuroradiol26:835838.

12. Maertens JA, Klont R, Masson C, Theunissen K, Meersseman W,Lagrou K, Heinen C, Crpin B, Van Eldere J, Tabouret M,Donnelly JP, Verweij PE, 2007. Optimization of the cutoff valuefor the Aspergillus double-sandwich enzyme immunoassay.Clin Infect Dis 44:13291336.

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Infection 34:333338.14. Denning DW, 1996. Therapeutic outcome of invasive aspergillosis.

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aspergilus flavus brain abscess

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