A rare, fatal case of invasive spinal aspergillosis in an antiretroviral-naïve, HIV-infected man with pre-existing lung colonization

Abstract

Infection of the central nervous system (CNS) is a rare but devastating complication of invasive aspergillosis. We report a case of invasive aspergillosis with spinal involvement in a human immunodeficiency virus (HIV)-infected patient without neutropenia. A 42-year-old, antiretroviralnaïve, HIV-infected man presented with progressive weakness in the lower limbs and urinary and faecal incontinence for 2 weeks. The patient had been prescribed broad-spectrum antibiotics and prednisone. He had upper motor neuron signs and a sensory level at T1, with accompanying neck stiffness on flexion. Magnetic resonance imaging revealed diffuse abnormal signals of the vertebral bodies in the lower cervical and thoracic areas, with cord compression in the C2 and C3 region and signal distortions of the T2 and T3 vertebral bodies. Chest X-ray and computerized tomography demonstrated post-tuberculous apical cavities with suspected fungal colonization. Histopathology of an extradural spinal lesion at T1/T2 suggested invasive aspergillosis. The patient was started on fluconazole in response to the histopathological evidence of Aspergillus infection, but died within 3 weeks. Post-mortem analysis of the biopsy sample by PCR identified the infectious agent as Aspergillus fumigatus. Atypically, his CD4 + T-cell count was 239 cells mm "3 and he had no evidence of neutropenia. Invasive aspergillosis should be considered as part of the differential diagnosis among HIV-infected patients with non-specific, focal CNS symptoms, even among those without classical risk factors such as neutropenia, and aggressive antifungal therapy should be instituted as early as possible. IntroductionAspergillus species are the most frequently isolated moulds among human immunodeficiency virus (HIV)-infected patients (Enoch et al., 2006), but invasive aspergillosis is very uncommon in this population (,1 %) (Cornet et al., 2002). Despite this low incidence, it is of particular importance because the case-fatality rate associated with disseminated infection or central nervous system (CNS) involvement is reported to be 88 % (Lin et al., 2001). Among HIV-infected persons, invasive aspergillosis usually occurs in patients with a CD4 + T-cell count of ,50 cells mm 23 and in those with neutropenia or on corticosteroids (Mylonakis et al., 1998). However, CNS aspergillosis has also been described in immunocompetent patients and following epidural steroid injections (Haran & Chandy, 1993; Larson Kolbe et al., 2007;Saigal et al., 2004;Sundaram et al., 2006). Aspergillosis generally affects the lungs, but can also spread to other organs, including the CNS. Based on a large, randomized-controlled trial, the drug of choice for invasive aspergillosis is voriconazole (Herbrecht et al., 2002). However, a diagnosis of invasive aspergillosis is often only made post-mortem, and a definitive diagnosis requires both microscopic analysis of tissue and identification of the organism by culture (Walsh et al., 2008).Aspergillus infection in the CNS is rare, but appears to be becoming mo...

Neuroinfections caused by fungi

“…Clinical manifestations include neurological deficits (50%), fever (45–50%), headache in patients with brain abscess (60%), oedema papillae nervi optici (25%), and seizures (25%). Less common symptoms include stiff neck, cranial or somatic nerve weakness, paresthesia, altered mental status, spinal cord compression, and very rare lethargy and coma [ 44 , 45 , 49 , 52 ]. X-ray and CT may show single or multiple aspergilloma in the brain, but this changes show no characteristic images and that is why the mentioned methods are not helpful in the diagnostics [ 54 ].…”

Cervico-Dorsal Intramedullary Spinal Cord Abscess with Aspergillus fumigates following Pulmonary Infection in an Immunocompetent Patient

“…Spinal cord biopsy revealed a caseating granuloma with fungal hyphae, morphologically consistent with Aspergillus species, but fungal cultures were negative. The patient was treated for 7 months with voriconazole and caspofungin, and then with posaconazole for another nine months, until she remained clinically stable [29].…”

Spinal epidural abscess caused by Aspergillus spp masquerading as spinal tuberculosis in a person with HIV

“…11,14 In keeping with a previous South African case reported by Rossouw et al (2011), our patient did not have a remarkably low CD4+ T cell count as one would expect. 15 A change in the epidemiology of invasive aspergillosis is being observed, and less classical, emerging risk factors have now been identified and should also be remembered when considering a diagnosis of IA. 16,17 These conditions include solid organ transplantation, chronic obstructive pulmonary disease (COPD), cytomegalovirus (CMV) infection and reactivation, liver disease, diabetes mellitus and Aspergillus infection in critically ill patients.…”