A fatal case of cerebral aspergillosis in a diabetes mellitus patient

Abstract

A 64-year-old right-handed diabetic man was presented into our hospital with 1 week history of left-sided limb weakness. One month ago he had been diagnosed with diabetes mellitus and the blood glucose level was poorly controlled. He compulsively reduced his intake and experienced unintentional weight loss. Apart from his limb weakness, he complained fever and progressive headaches in the last 2 weeks. His highest temperature was 40°C. Past medical history was negative for tuberculosis, bone marrow and solid organ transplantation and malignancy. Moreover, there was no history of steroid or other immunosuppressive drug consumption.On physical examination, his general condition was poor as a result of malnutrition. The neurological examination revealed that left hemiplegia and meningeal irritation signs were positive. The serum complete blood count showed a white cell count of 10,210/mm 3 with 76.4 % neutrophils. The glucose level was 632 mg/dL. Viral markers were negative. Lumbar puncture was performed and the opening pressure was 245 cm H 2 O. Cerebrospinal fluid (CSF) contained a white cell count of 522/mm 3 (94 % neutrophils), a protein concentration of 102.2 mg/dL, and a glucose concentration of 95 mg/dL. The chest X-ray was normal. After admission, cranial computed tomography (CT) scan showed a hypointense lesion on right basal ganglia area. Diffusion magnetic resonance imaging (MRI) showed restricted diffusion in the same area.He was initially treated for an acute ischaemic stroke and administered aspirin and rosuvastatin, but his condition sharply deteriorated. Three days after presentation, the second CT scan revealed a hyperintense lesion with surrounding brain edema (Fig. 1). Two days later, he slipped into a coma. Subsequent MRI revealed an occupying lesion with high density and moderate mass in the frontal lobe, with edema in the surrounding area. The lesion showed slightly low signal intensity in T1-weighted sequences with strong enhancement.A right pterional approach craniotomy was performed for pathologic diagnosis and excision of brain abscess. The surgical specimens showed many vessels thrombosis,haemorrhage, inflammatory granulation tissue. Periodic acid-Schiff stain demonstrated a small vessel invasion by septate hyphae of aspergillosis (Fig. 2). During the postoperative period, the patient was treated with intravenous voriconazole. Unfortunately, his health condition deteriorated and he died on hospital day 27.