2. Case History
Mr A 39 year old farmer from Vellore presented
with :
• Fever ,headache x10 days
• Right upper and lower limb weakness x1 day
• Right sided focal seizures x1 day
• Persistent drowsiness following the seizure
3. On examination
• patient was somnolent with GCS of 11/15 with
delayed reaction time.
• There was right sided hemiparesis with right UMN
facial palsy and meningeal signs
4. Clinical impression
• In view of prior fever ,headache and current
altered sensorium with focal deficits and
meningeal signs --
acute meningoencephalitis
5.
6. Investigations
• CSF showed lymphocytic pleocytosis with
elevated protein low glucose.all cultures and
blood serologies were negative.
• He was HIV negative
• PET brain showed a hypermetabolic focus in
the corresponding regions.
8. Course in hospital
• Progressive worsening in clinical condition
over the next few days with development of
multiple focal seizures.
• His sensorium depressed and required
intubation,mechanical ventilation.
10. Figure (a) shows nervous tissue with foci of microabscess formation comprising of
neutrophils and karyorrhectic debris. Also seen are ill-formed aggregates of
histiocytes, Langhans type and foreign body type multinucleated giant cells and (b)
highlights the septate, branching fungal hyphae and yeast forms of fungal micro-
organisms, suggestive of aspergillus(PAS with diastase).
(a
)
(b)
Histopathology
11. • Left frontal biopsy (with decompressive craniectomy)
• Reactive gliosis, microabscesses,
perivascular, transmural and parenchymal
inflammation with Few septate fungal hyphae ,
suggestive of aspergillus(PAS with diastase).
• Culture: Aspergillus flavus (Septate hyphae)
12. Summary
• Patient diagnosed as Invasive cerebral aspergillosis
presenting as meningoencephalitis with vasculitis
and abscess formation.
• Since he was seronegative for HIV , was worked up
for other causes of immunodeficiency like:
-- CD 4 lymphocytopenia
--chronic granulomatous disease(dihydrorhodamine
test), immunoglobulin levels were all negative.
13. • He was initiated on Voriconozole
• Discharged in a minimally concious state on
tracheostomy with residual deficits
• This case is unusual as there was no evidence
of paranasal sinus involvement or lung
involvement (usual portal of entry) and that it
happened in an immumocompetent individual
14. Invasive cerebral aspergillosis
• May not have evidence of PNS, lung involvement
• Angioinvasion, presentation with bleeds
• Cerebral aspergillosis in immunocompetent may not
be very rare
• Virulent and drug resistant forms occur
• Surgical intervention needed in most cases
• HIV, CGD, post transplant patients
MRI BRAIN gado showed mutiple nodular enhancing lesions in the left periventricular white
matter of the frontoparietal region with meningeal enhancement and smaller lesions on the right
periventricular regions
MRI brain showed worsening edema and mass effect in the left periventricular region
and midline shift .Lesions were currently diffusion restricting and there were micro hemorrhage
He underwent a frontal decompressive craniectomy and brain biopsy
