Neuroradiolngv
Neuroradiology 17, 111-113 (1979)
© by Springer-Verlag 1979
Computed Tomography and Intracranial Aspergillosis R. J. Tully and C. Watts Department of Radiologyand Sectionof Neurosurgery, Universityof MissouriMedicalCenter, Columbia, USA
Summary. A case of aspergillosis of the central nervous system with multiple granulomas examined by computed tomography is reported. The findings are those of chronic mass lesions with and without calcium deposits. An associated cystic configuration probably is not specific for aspergi!lomas.
pathological correlation with similar clinical conditions [1]. Since apparently no case of intracranial aspergillosis has been examined by computed tomography [14] the following case is reported.
Case Report Key words: Aspergillosis - Computed tomography
Introduction Although excellent experimental data support its use [7, 12], many of the interpretations of computed tomographic images are based upon repeated
A boy aged 14 years was admitted with progressive left hemiparesis and intracranial calcification. At the age of 4 years he was admitted to the hospital with a right middle lobe infiltrate which was subsequently diagnosed as pulmonary aspergillosis. A few weeks later, following the development of papilledema and widening of cranial sutures, a right cerebellar aspergillioma was removed. He had sev-
Fig. 1. Skull, AP and lateral. Multiple intracerebral calcificationsgrouped primarilyanteriorlyand on right 0028-3940/79/0017/0111/$01.00
112
R.J. Tully and C. Watts: ComputedTomography and Intracranial Aspergillosis
Fig. 2. Cranial computedtomography. Multiplecalcified areas in both cerebral hemispheres (A, B, D). Cysticcavity deep within right cerebralhemispherewith associatedmass effect (B, C, D) tomography (EMI) localized the intracranial calcifications to the cerebral hemispheres, largely on the right side (Fig. 2). One area of calcification was adjacent to a large cystic area in the center of the right cerebral hemisphere which distorted and essentially obliterated the body and temporal horn of the right lateral ventricle. A craniotomy was performed and the wall of the cyst biopsied. Pathological examination demonstrated gliosis without a distinct fibrous or ependymal lined capsule and the branched hyphae characteristic of the aspergillus organism (Fig. 3).
Discussion
Fig. 3. Photomicrograph demonstrating branched hypae (arrow') eral admissions to hospital for pulmonary disease over the next few years. During one of these admissions it was established that he had a cellular form of immunodeficiency which was sex linked and resulted in chronic granulomatosis. A younger sibling had a similar condition. The hemiparesis had developed progressively over approximately 1 year. Skull films revealed scattered intracranial calcifications (Fig. 1). C o m p u t e d
Aspergillosis is a granulomatose disease due to a ubiquitous saprophytic fungus, aspergillus. While most infections have been caused by A. fumigatus, A. niger and A. flavus have also been implicated [4]. Infection of the central nervous system (CNS) is quite rare. It has been estimated that less than 70 cases of CNS aspergillosis have been reported [16]. In 98 patients with aspergillosis, only 13 had CNS involvement [ 18]. Most cases of CNS aspergillosis are associated with systemic involvement in patients debilitated by'neoplastic disease [18] or with immune responses depressed iatrogenically by corticosteroids or immunosuppressive agents, or with opportunistic infections related to antibiotic therapy [5]. The case reported here involves a patient with a genetic immune deficiency characterized by chronic granu-
R. J. Tully and C. Watts: Computed Tomography and Intracranial Aspergillosis
lomatosis. A few cases have been reported involving patients with narcotic habits [11], or in good health but with occupational exposure to the aspergillus fungus [13]. Aspergillosis of the CNS may appear clinically in a variety of ways [6]. Almost all patients have evidence of systemic involvement, usually with pulmonary disease [8]. Unusual presentations include unilateral exophthalmos [10] and occlusion of the internal carotid artery [17]. The pathological process may involve the CNS in several ways. Acute symptoms of meningitis, cerebritis, or early brain abscess may be seen [15]. Chronic meningitis with cranial nerve involvement, especially the trigeminal nerve, occurs [19]. Hematogenous dissemination with thrombosis of vessels, and mycotic aneurysms [2, 13] with subarachnoid hemorrhage [3] have been reported. Granulomas, often multiple, may present with progressing signs and symptoms of mass lesions [15], as occurred in the case being reported. The diagnosis of CNS aspergillosis is likely to be made only if a fungal infection is suspected [10]. A presumptive diagnosis may be inferred in patients with neurological symptoms who have known systemic aspergillosis, diagnosed by successful culture of non-CNS tissue, e.g. blood, urine, lung, endocardium. Negative or non-specifically abnormal CSF analysis may not be helpful in excluding the disease because of difficulty in locating the organism, even if meningitis is present [18]. Plain skull films may demonstrate calcification in aspergillus granulomas, which is not unlike that found with other chronic granulomas and some tumors [9, 18]. Radionuclide brain scanning occasionally is rewarding, but only to the extent that foci of cerebritis or abscesses are present [15]. Although cerebral angiography and contrast encephalography are the two most useful noxious diagnostic procedures for patients with CNS aspergillomas, no pathognomonic neuroradiological features of cerebral aspergillosis have been reported [15]. We found computed tomography to be very helpful in delineating the location and character of the multiple lesions present in our patient. However, no finding felt to be diagnostic of aspergillosis was noted. The calcium deposits are readily seen, and do not differ from those described with other granulomatous conditions. The solid solitary lesions, without significant edema, are found with other chronic disorders. The character of the cystic lesion could not be identified pathologically and could have been either a glia-walled cyst or a partially obstructed temporal horn. It did not appear to be characteristic of the aspergilloma, as similar lesions are seen with other granulomas.
113
References 1. Ambrose, J.: Computerized transverse axial scanning (tomography): Part II. Clinical application. Br. J. Radiol. 46, 1023--1049 (1973) 2. Correa, A.J.E., Brinkhaus, R., Kesler, S., Martinez, E.: Aspergillosis of the fourth ventricle. J. Neurosurg. 43, 236-238 (1975) 3. Davidson, P., Robertson, D.M.: A true mycotic aneurysm leading to fatal subarachnoid hemorrhage in a patient with hereditary hemorrhagic telangiectasia. J. Neurosurg, 35, 71-76 (1971) 4. Emmons, C. W., Binford, C. H., Utz, I. P.: Medical mycology. Philadelphia: Lea and Febiger, 1970 5. Feingold, S. M., Will, D., Murry, J. E.: Aspergillosis, a review and report of twelve cases. Am. J. Med. 27, 463-482 (1959) 6. Fetter, B.F., Klintworth, G.K., Hendrix, W. S.: Mycoses of the central nervous system. Baltimore: Williams and Wilkins 1967 7. Hounsfield, G.M.: Computerized transverse axial scanning (tomography): Part I. Description of system. Br. J. Radiol. 46, 1016-1022 (1973) 8. Hutter, R. V. P., Lieberman, P. H,, Collins, H.S.: Aspergillosis in a cancer hospital. Cancer 17, 747-756 (1964) 9. Iver, S., Dodge, P.R., Adams, R.D.: Two cases of aspergilIosis infection of the central nervous system. J. Neurol. Neurosurg. Psychiat. 15, 152-163 (1952) 10. Jackson, I.J., Earle, K., Kuri, J.: Solitary aspergillosis granuloma of the brain. J. Neurosurg. 12, 53-61 (1955) 11. Kaufman, D.M., Thal, L.J., Farmer, P.M.: Central nervous system aspergillosis in two young adults. Neurology 26, 484-488 (1976) 12. McCullough, E.C., Baker, H.J., Houser, O.W., et al.: An evaluation of the quantitative and radiation features of a scanning X-ray transverse axial tomograph: The EMI scanner. Radiology 11l, 709-715 (1974) 13. Mukoyama, M., Gimple, K., Poser, C. M.: Aspergillosis of the central nervous system. Neurology, 19, 967-974 (1969) 14. New, P.F., Scott, W. R.: Computed tomography of the brain and orbit, EMI scanning, pp. 486. Baltimore: Williams and Wilkins, 1975 15. Shapiro, K., Tabaddor, K.: Cerebral aspergillosis. Surg. Neurol. 4, 465-471 (1975) 16. Visudhiphon, P., Bunyaratavey, S., Khantanaphar, S.: Cerebral aspergillosis: report of three cases. J. Neurosurg. 33, 472-476 (1973) 17. Wollschlaeger, G., Wollschlaeger, P. B., Lopez, V. F. et al.: A rare cause of occlusion of the internal carotid artery. Neuroradiology 1, 32-38 (1970) 18. Young, R. C., Bennett, J. E., Vogel, C. L., et al.: Aspergillosis: The spectrum of the disease in 98 patients. Medicine 49, 147-173 (1970) 19. Ziskind, J., Pizzolato, P., Buff, E.E.: Aspergillosis of the brain: report of a case. Am. J. din. Path. 29, 554-559 (1958) Received: 20 December 1977
Dr. R. Tully University of Missouri Medical Center Columbia, MO 65212, USA
Neuroradiology 17, 111-113 (1979)
© by Springer-Verlag 1979
Computed Tomography and Intracranial Aspergillosis R. J. Tully and C. Watts Department of Radiologyand Sectionof Neurosurgery, Universityof MissouriMedicalCenter, Columbia, USA
Summary. A case of aspergillosis of the central nervous system with multiple granulomas examined by computed tomography is reported. The findings are those of chronic mass lesions with and without calcium deposits. An associated cystic configuration probably is not specific for aspergi!lomas.
pathological correlation with similar clinical conditions [1]. Since apparently no case of intracranial aspergillosis has been examined by computed tomography [14] the following case is reported.
Case Report Key words: Aspergillosis - Computed tomography
Introduction Although excellent experimental data support its use [7, 12], many of the interpretations of computed tomographic images are based upon repeated
A boy aged 14 years was admitted with progressive left hemiparesis and intracranial calcification. At the age of 4 years he was admitted to the hospital with a right middle lobe infiltrate which was subsequently diagnosed as pulmonary aspergillosis. A few weeks later, following the development of papilledema and widening of cranial sutures, a right cerebellar aspergillioma was removed. He had sev-
Fig. 1. Skull, AP and lateral. Multiple intracerebral calcificationsgrouped primarilyanteriorlyand on right 0028-3940/79/0017/0111/$01.00
112
R.J. Tully and C. Watts: ComputedTomography and Intracranial Aspergillosis
Fig. 2. Cranial computedtomography. Multiplecalcified areas in both cerebral hemispheres (A, B, D). Cysticcavity deep within right cerebralhemispherewith associatedmass effect (B, C, D) tomography (EMI) localized the intracranial calcifications to the cerebral hemispheres, largely on the right side (Fig. 2). One area of calcification was adjacent to a large cystic area in the center of the right cerebral hemisphere which distorted and essentially obliterated the body and temporal horn of the right lateral ventricle. A craniotomy was performed and the wall of the cyst biopsied. Pathological examination demonstrated gliosis without a distinct fibrous or ependymal lined capsule and the branched hyphae characteristic of the aspergillus organism (Fig. 3).
Discussion
Fig. 3. Photomicrograph demonstrating branched hypae (arrow') eral admissions to hospital for pulmonary disease over the next few years. During one of these admissions it was established that he had a cellular form of immunodeficiency which was sex linked and resulted in chronic granulomatosis. A younger sibling had a similar condition. The hemiparesis had developed progressively over approximately 1 year. Skull films revealed scattered intracranial calcifications (Fig. 1). C o m p u t e d
Aspergillosis is a granulomatose disease due to a ubiquitous saprophytic fungus, aspergillus. While most infections have been caused by A. fumigatus, A. niger and A. flavus have also been implicated [4]. Infection of the central nervous system (CNS) is quite rare. It has been estimated that less than 70 cases of CNS aspergillosis have been reported [16]. In 98 patients with aspergillosis, only 13 had CNS involvement [ 18]. Most cases of CNS aspergillosis are associated with systemic involvement in patients debilitated by'neoplastic disease [18] or with immune responses depressed iatrogenically by corticosteroids or immunosuppressive agents, or with opportunistic infections related to antibiotic therapy [5]. The case reported here involves a patient with a genetic immune deficiency characterized by chronic granu-
R. J. Tully and C. Watts: Computed Tomography and Intracranial Aspergillosis
lomatosis. A few cases have been reported involving patients with narcotic habits [11], or in good health but with occupational exposure to the aspergillus fungus [13]. Aspergillosis of the CNS may appear clinically in a variety of ways [6]. Almost all patients have evidence of systemic involvement, usually with pulmonary disease [8]. Unusual presentations include unilateral exophthalmos [10] and occlusion of the internal carotid artery [17]. The pathological process may involve the CNS in several ways. Acute symptoms of meningitis, cerebritis, or early brain abscess may be seen [15]. Chronic meningitis with cranial nerve involvement, especially the trigeminal nerve, occurs [19]. Hematogenous dissemination with thrombosis of vessels, and mycotic aneurysms [2, 13] with subarachnoid hemorrhage [3] have been reported. Granulomas, often multiple, may present with progressing signs and symptoms of mass lesions [15], as occurred in the case being reported. The diagnosis of CNS aspergillosis is likely to be made only if a fungal infection is suspected [10]. A presumptive diagnosis may be inferred in patients with neurological symptoms who have known systemic aspergillosis, diagnosed by successful culture of non-CNS tissue, e.g. blood, urine, lung, endocardium. Negative or non-specifically abnormal CSF analysis may not be helpful in excluding the disease because of difficulty in locating the organism, even if meningitis is present [18]. Plain skull films may demonstrate calcification in aspergillus granulomas, which is not unlike that found with other chronic granulomas and some tumors [9, 18]. Radionuclide brain scanning occasionally is rewarding, but only to the extent that foci of cerebritis or abscesses are present [15]. Although cerebral angiography and contrast encephalography are the two most useful noxious diagnostic procedures for patients with CNS aspergillomas, no pathognomonic neuroradiological features of cerebral aspergillosis have been reported [15]. We found computed tomography to be very helpful in delineating the location and character of the multiple lesions present in our patient. However, no finding felt to be diagnostic of aspergillosis was noted. The calcium deposits are readily seen, and do not differ from those described with other granulomatous conditions. The solid solitary lesions, without significant edema, are found with other chronic disorders. The character of the cystic lesion could not be identified pathologically and could have been either a glia-walled cyst or a partially obstructed temporal horn. It did not appear to be characteristic of the aspergilloma, as similar lesions are seen with other granulomas.
113
References 1. Ambrose, J.: Computerized transverse axial scanning (tomography): Part II. Clinical application. Br. J. Radiol. 46, 1023--1049 (1973) 2. Correa, A.J.E., Brinkhaus, R., Kesler, S., Martinez, E.: Aspergillosis of the fourth ventricle. J. Neurosurg. 43, 236-238 (1975) 3. Davidson, P., Robertson, D.M.: A true mycotic aneurysm leading to fatal subarachnoid hemorrhage in a patient with hereditary hemorrhagic telangiectasia. J. Neurosurg, 35, 71-76 (1971) 4. Emmons, C. W., Binford, C. H., Utz, I. P.: Medical mycology. Philadelphia: Lea and Febiger, 1970 5. Feingold, S. M., Will, D., Murry, J. E.: Aspergillosis, a review and report of twelve cases. Am. J. Med. 27, 463-482 (1959) 6. Fetter, B.F., Klintworth, G.K., Hendrix, W. S.: Mycoses of the central nervous system. Baltimore: Williams and Wilkins 1967 7. Hounsfield, G.M.: Computerized transverse axial scanning (tomography): Part I. Description of system. Br. J. Radiol. 46, 1016-1022 (1973) 8. Hutter, R. V. P., Lieberman, P. H,, Collins, H.S.: Aspergillosis in a cancer hospital. Cancer 17, 747-756 (1964) 9. Iver, S., Dodge, P.R., Adams, R.D.: Two cases of aspergilIosis infection of the central nervous system. J. Neurol. Neurosurg. Psychiat. 15, 152-163 (1952) 10. Jackson, I.J., Earle, K., Kuri, J.: Solitary aspergillosis granuloma of the brain. J. Neurosurg. 12, 53-61 (1955) 11. Kaufman, D.M., Thal, L.J., Farmer, P.M.: Central nervous system aspergillosis in two young adults. Neurology 26, 484-488 (1976) 12. McCullough, E.C., Baker, H.J., Houser, O.W., et al.: An evaluation of the quantitative and radiation features of a scanning X-ray transverse axial tomograph: The EMI scanner. Radiology 11l, 709-715 (1974) 13. Mukoyama, M., Gimple, K., Poser, C. M.: Aspergillosis of the central nervous system. Neurology, 19, 967-974 (1969) 14. New, P.F., Scott, W. R.: Computed tomography of the brain and orbit, EMI scanning, pp. 486. Baltimore: Williams and Wilkins, 1975 15. Shapiro, K., Tabaddor, K.: Cerebral aspergillosis. Surg. Neurol. 4, 465-471 (1975) 16. Visudhiphon, P., Bunyaratavey, S., Khantanaphar, S.: Cerebral aspergillosis: report of three cases. J. Neurosurg. 33, 472-476 (1973) 17. Wollschlaeger, G., Wollschlaeger, P. B., Lopez, V. F. et al.: A rare cause of occlusion of the internal carotid artery. Neuroradiology 1, 32-38 (1970) 18. Young, R. C., Bennett, J. E., Vogel, C. L., et al.: Aspergillosis: The spectrum of the disease in 98 patients. Medicine 49, 147-173 (1970) 19. Ziskind, J., Pizzolato, P., Buff, E.E.: Aspergillosis of the brain: report of a case. Am. J. din. Path. 29, 554-559 (1958) Received: 20 December 1977
Dr. R. Tully University of Missouri Medical Center Columbia, MO 65212, USA
![[The different manifestations of pulmonary aspergillosis: multidetector computed tomography findings].](/assets/img/hold.png)
