Stuck in my head as an old song

Published:October 22, 2021DOI:https://doi.org/10.1016/j.ejim.2021.10.007

      1. Main section

      A 61-year-old piano man was admitted to the emergency department for loss of consciousness, aphasia and Glasgow coma scale of 13 points. His past medical history included hypertension, non-insulin-dependent diabetes mellitus and occasional inhalation of cocaine.
      A computed tomography scan (Figure 1A) showed left cerebral frontal abscessual lesion approximately of 3,5 cm in diameter and initial ventriculitis confirmed by magnetic resonance imaging (Figure 1B). After lumbar puncture cerebrospinal fluid (CSF) showed 2,822 cells/mm3 (90% of polymorphonucleates), high proteinorrachia (345 g/dl), and hypoglycorrhachia (67 g/dl; blood sugar 180 g/dL). Empirical cefepime plus metronidazole were started.
      Due to neurological impairment and respiratory distress, the patient was admitted to the intensive care unit and underwent endotracheal intubation. A surveillance nasal swab showed multiple hyphae and isavuconazole was started, obtaining progressive clinical and radiological improvement with the recovery of consciousness, reduction of the lesion size and respiratory weaning.
      A new lumbar puncture tested positive for galactomannan (index 1.9; normal value 0.5). Dry colonies grew on CSF culture on Sabouraud's dextrose agar medium and a microscopic smear showed hyphae with a single series of phialides, giving origin to the rounded conidia disposed in long and parallel chains (Figures 1C and 1D).

      2. What is the diagnosis?

      Cerebral aspergillosis is an opportunistic fungal infection that usually affects seriously immunocompromised hosts, typically those with prolonged neutropenia, haematopoietic stem cell and solid organ transplant recipients, acquired Immunodeficiency syndrome, high dosing steroids and hematologic malignancies [
      • Patterson TF
      • Thompson 3rd, GR
      • Denning DW
      • et al.
      Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America.
      ]. However, an increasing number of reports of cerebral aspergillosis in immunocompetent patients and cocaine inhalation have been reported in few cases in association with aspergillosis, especially in chronic rhinosinusitis [
      • Azulay-Abulafia L
      • Sousa MA
      • Pussanti A
      • Coimbra DD
      • Vega H
      • Bernardes Filho F
      Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction.
      ,
      • Pekala KR
      • Clavenna MJ
      • Shockley R
      • Weiss VL
      • Turner JH
      Chronic invasive fungal sinusitis associated with intranasal drug use.
      ]. The pathomorphosis of ventriculitis, as shown in the MRI, is more consistent with cerebral aspergilloma than with ventriculitis secondary to intracranial abscess rupture.

      Declaration of Competing Interest

      The authors declare that they have no conflict of interest.

      Ethical standards

      The patient provided a written consent for the use of his clinical data for scientific purposes.

      Acknowledgments

      We thank Doctor Erika Concialdi for the microbiological support

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        Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction.
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