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CASE REPORT
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Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI Seiko Hirota, Shinji Ito, Takao Fukui, Kenichiro Murate, Sayuri Shima, Madoka Kizawa, Akihiro Ueda, Kunihiko Asakura and Tatsuro Mutoh
Abstract A 74-year-old woman was hospitalized due to dysuria, weakness and dysesthesia of the lower extremities. She was in an immunosuppressed state following the administration of methylprednisolone therapy for idiopathic interstitial pneumonia. Cerebrospinal fluid and blood cultures were negative, and no infectious biomarkers were found. A gadolinium (Gd)-enhanced T1-weighted image of magnetic resonance imaging (MRI) revealed disseminated nodular lesions along the spinal cord. We suspected a diagnosis of seronegative deep mycosis and initiated anti-fungal therapy with voriconazole, which subsequently alleviated all of the patient’s symptoms and MRI findings. Therefore, the presence of Gd-enhanced disseminated nodules on spinal MRI may be a good marker of deep meningeal mycosis. Key words: meningitis, deep mycosis, MRI, voriconazole (Intern Med 54: 215-218, 2015) (DOI: 10.2169/internalmedicine.54.3148)
Introduction Deep mycosis is a common complication in immunocompromised patients, in whom obtaining a definitive diagnosis is often difficult, even with typical imaging techniques and laboratory tests (1). Available fungal antigens and antibodies generally only cover common pathogens. (1,3)-β-D-glucan is a useful marker of mycosis, although it shows insufficient sensitivity for deep or minor infections (2), and some types of rare yeasts other than Candida species have no available surrogate markers. To date, specific neuroimaging findings for mycotic infections of the central nervous system (CNS) have not been established. Some cases of aspergillosis, cryptococcosis and candidiasis have been reported to involve neuroimaging characteristics suggesting the presence of intracranial abscesses (3); however, supportive evidence, such as the presence of specific antigens and/or special histopathology, is required for a definitive diagnosis. In various rare and emerging fungal infections, including mucormycosis and hyalohyphomycosis, it is more difficult to make a correct diagnosis due to the lack of serological markers. Therefore, the detection of nonseptate hyphae in fluid and/or tissue in
patients with sinusitis at autopsy may provide definitive evidence for a diagnosis of mucormycosis (4, 5). In this report, we describe an intriguing case of voriconazole-responsive disseminated nodular lesions along the spinal cord.
Case Report A 74-year-old woman was hospitalized due to dysuria, weakness and dysesthesia of the lower extremities. The patient had received intensive methylprednisolone therapy (methylprednisolone 1 g/day, 12 times per month) for idiopathic interstitial pneumonia for one month prior to admission. A neurological examination performed on admission revealed moderate weakness in the lower limbs, hyperesthesia of the distal portions of the extremities, hyporeflexia without pathological reflexes and urinary retention. A mild headache was also noted; however, a fever and meningeal signs were absent. A cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis (234 cells/μL; normal
CASE REPORT
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Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI Seiko Hirota, Shinji Ito, Takao Fukui, Kenichiro Murate, Sayuri Shima, Madoka Kizawa, Akihiro Ueda, Kunihiko Asakura and Tatsuro Mutoh
Abstract A 74-year-old woman was hospitalized due to dysuria, weakness and dysesthesia of the lower extremities. She was in an immunosuppressed state following the administration of methylprednisolone therapy for idiopathic interstitial pneumonia. Cerebrospinal fluid and blood cultures were negative, and no infectious biomarkers were found. A gadolinium (Gd)-enhanced T1-weighted image of magnetic resonance imaging (MRI) revealed disseminated nodular lesions along the spinal cord. We suspected a diagnosis of seronegative deep mycosis and initiated anti-fungal therapy with voriconazole, which subsequently alleviated all of the patient’s symptoms and MRI findings. Therefore, the presence of Gd-enhanced disseminated nodules on spinal MRI may be a good marker of deep meningeal mycosis. Key words: meningitis, deep mycosis, MRI, voriconazole (Intern Med 54: 215-218, 2015) (DOI: 10.2169/internalmedicine.54.3148)
Introduction Deep mycosis is a common complication in immunocompromised patients, in whom obtaining a definitive diagnosis is often difficult, even with typical imaging techniques and laboratory tests (1). Available fungal antigens and antibodies generally only cover common pathogens. (1,3)-β-D-glucan is a useful marker of mycosis, although it shows insufficient sensitivity for deep or minor infections (2), and some types of rare yeasts other than Candida species have no available surrogate markers. To date, specific neuroimaging findings for mycotic infections of the central nervous system (CNS) have not been established. Some cases of aspergillosis, cryptococcosis and candidiasis have been reported to involve neuroimaging characteristics suggesting the presence of intracranial abscesses (3); however, supportive evidence, such as the presence of specific antigens and/or special histopathology, is required for a definitive diagnosis. In various rare and emerging fungal infections, including mucormycosis and hyalohyphomycosis, it is more difficult to make a correct diagnosis due to the lack of serological markers. Therefore, the detection of nonseptate hyphae in fluid and/or tissue in
patients with sinusitis at autopsy may provide definitive evidence for a diagnosis of mucormycosis (4, 5). In this report, we describe an intriguing case of voriconazole-responsive disseminated nodular lesions along the spinal cord.
Case Report A 74-year-old woman was hospitalized due to dysuria, weakness and dysesthesia of the lower extremities. The patient had received intensive methylprednisolone therapy (methylprednisolone 1 g/day, 12 times per month) for idiopathic interstitial pneumonia for one month prior to admission. A neurological examination performed on admission revealed moderate weakness in the lower limbs, hyperesthesia of the distal portions of the extremities, hyporeflexia without pathological reflexes and urinary retention. A mild headache was also noted; however, a fever and meningeal signs were absent. A cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis (234 cells/μL; normal
