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Letter
Mycotic Brain Abscess Caused
by Opportunistic Reptile Pathogen
Christoph Steininger,*
Jan van Lunzen,* Kathrin Tintelnot,† Ingo Sobottka,* Holger Rohde,* Matthias
Ansver Horstkotte,* and Hans-Jürgen Stellbrink*
*University Clinic Eppendorf, Hamburg, Germany; and †Robert Koch-Institut,
Mykologie, Berlin, Germany
Suggested
citation for this article
To the Editor: A 38-year-old, HIV-seropositive Nigerian man sought
treatment with an 8-month history of severe parietal headache, impaired
memory, fatigue, paresthesia of the left arm, and left-sided focal seizures.
He had no history of neurologic disorders, including epilepsy. On physical
examination, the patient appeared well, alert, and oriented, with slurred
speech. Evaluation of the visual fields showed left homonymous hemianopsia.
All other neurologic assessments were unremarkable. The patient had a
blood pressure of 120/80, a pulse of 88 beats per minute, and a body temperature
of 37.3°C. Leukocyte count was 8,600/µL, total lymphocyte count
was 1,981/µL, CD4+ cell count was 102/µL, and CD4/CD8 ratio
was 0.07. HIV RNA-load was <50 copies/mL; all other laboratory parameters
were normal. The patient had received antiretroviral therapy (stavudine,
lamivudine, nevirapine) for 5 months before admission, but no prophylaxis
for opportunistic infections. Magnetic resonance imaging (MRI) of the
brain disclosed 2 masses, 3.3 and 4.8 cm in diameter, respectively (Figure
A), and signs of chronic sinusitis. A computed tomographic chest scan
showed infiltration of both lower segments with multiple, small nodules
(Figure B). Blood cultures were repeatedly negative.
A computer-guided needle-aspiration of the brain lesions yielded yellow-brown,
creamy fluid in which abundant septated fungal hyphae were detected microscopically
(Figure C). Cytologic investigation was consistent
with a necrotic abscess. The cycloheximide-resistant isolate was strongly
keratinolytic and identified as a Chrysosporium anamorph of Nannizziopsis
vriesii (1,2). High-dose antimicrobial treatment
with voriconazole (200 mg twice daily, subsequently reduced to 200 mg
daily) was added to the antiretroviral (ritonavir, amprenavir, trizivir),
anticonvulsive, and adjuvant corticosteroid treatment. The isolate was
highly susceptible to voriconazole in vitro (MIC, <16µg/mL
[Etest, AB-Biodisk Solna, Sweden]). Recovery was complicated by a generalized
seizure and severe, acute psychosis associated with rapid refilling of
the 2 lesions with mycotic abscess fluid. After re-aspiration, the patient's
psychosis improved gradually, and no further seizures occurred. When last
seen 4 months later, the patient was healthy and without neurologic deficits.
His CD4+ cell count was 233/µL, HIV-load was <50 copies/mL, and
a MRI scan of the brain showed partial regression of the 2 brain lesions
(Figure D).
Chrysosporium spp. are common soil saprobes, occasionally isolated
from human skin. Invasive infection is very rare in humans, and most were
observed in immunocompromised patients, manifesting as osteomyelitis (3,4)
or diffuse vascular brain invasion (5). Here, we report
the first case of brain abscesses by the Chrysosporium anamorph
of N. vriesii. This fungus has been associated with fatal mycosis
in reptiles (6,7) and cutaneous mycosis in chameleons
originating from Africa (2).
In our patient, we were unable to determine the portal of entry and the
sequence of fungal dissemination; no skin lesions were present at the
time of admission. However, the multifocal nature, lung infiltration,
and involvement of the middle cerebral artery distribution suggest hematogenous
dissemination (8,9) after replication of airborne conidia
within the respiratory tract.
Fungi cause >90% of brain abscesses in immunocompromised transplant
patients with an associated mortality rate of 97% (10),
despite aggressive surgery and antifungal therapy (9).
Our patient was treated successfully with abscess drainage, antiretroviral
therapy, and oral voriconazole, a novel antifungal triazole drug. Despite
limited data available on voriconazole penetration into brain abscess
cavities (9), this drug was clinically and radiologically
effective in our patient.
Acknowledgments
We thank the patient
for cooperating with our investigation, Pfizer Germany for providing
voriconazole, and Heidemarie Losert and Elisabeth Antweiler for their
excellent technical assistance.
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Suggested citation
for this article:
Steininger C, van Lunzen
J, Tintelnot K, Sobottka I, Rohde H, Horstkotte MA, et al. Mycotic brain
abscess caused by opportunistic reptile pathogen [letter]. Emerg Infect
Dis [serial on the Internet]. 2005 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol11no02/04-0915.htm
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