Large cerebellar mass lesion: A rare intracranial manifestation of blastomycosis
The patient is a 63-year-old man with a history of non-Hodgkin's lymphoma 9 years prior; he had sustained remission after treatment with chemotherapy and radiation. He had presented with persistent nausea and vomiting for 2 months prior to his transfer to our institution. The patient underwent multiple gastrointestinal studies, which did not reveal a clear etiology of his symptoms. Routine chest X-ray demonstrated nonspecific left upper lobe opacities that were further evaluated with computed tomography (CT) and determined to be consistent with pneumonia. Head CT demonstrated a hypodense right cerebellar lesion that minimally enhanced with contrast [Figure and ], prompting further investigation with magnetic resonance imaging (MRI). This revealed an enhancing right cerebellar mass with surrounding cystic lesions causing compression of the 4th ventricle and dorsal medulla resulting in obstructive hydrocephalus [Figure –].\nThe patient underwent a suboccipital craniotomy, finding an intradural lesion that was adherent to the surrounding meninges. Dissection around the lesion revealed a firm, avascular mass with surrounding cystic structures that were filled with yellow fluid. Gross total resection of the mass lesion and surrounding cystic structures was achieved.\nThe patient recovered from surgery well and his nausea and vomiting slowly resolved. Pathology and microbiologic analysis revealed fungal elements and budding yeast consistent with blastomycosis [Figure –]. There was no evidence of CNS dissemination. The patient was started on antifungal therapy with amphotericin B. He was able to tolerate 1 week of amphotericin B before he developed acute hepatitis, prompting its discontinuation. At that time, he was switched to voriconazole. Treatment with voriconazole was planned to last for 1 year.\nAt last follow up, the patient had mild ataxia. His MRI performed 1 month after surgery demonstrated expected postoperative changes and improvement in ventricular dilation seen preoperatively; there was no evidence of recurrent infection [].