Cerebral Aspergillosis with Multiple Enhancing Nodules in the Right Cerebral Hemisphere in the Immune-Competent Patient
A 48-year-old man with diabetes mellitus, presented to the department of ophthalmology with the complaints of blurred vision that persisted for one month. There was defected visual accuracy in the left eye about 18 years ago. In ophthalmologic examination, there was no new lesion in the both eyes. The laboratory examinations were within normal range. The random blood glucose was 164 mmol/L and the glycosylated hemoglobin was 8.1%. Upon further evaluation, magnetic resonance imaging (MRI) of the brain showed a low-signal intensity on T1-wighted images and a high-signal intensity on T2-weighed images (). After gadolinium enhancement, multiple nodular enhancing lesions with or without a focal necrotic area were shown in the right frontotemporoparietal cortex and white matter (). The diffusion image appeared with high-signal intensity in these areas (). The magnetic resonance spectroscopy obtained from the right occipital region showed elevated lactate/lipid peaks, with mild decreased N-acetylaspartate and no elevation of choline, which suggested necrotic conditions. The lumbar-puncture examination cerebrospinal fluid did not show any infection signs. The body fluid parasite and anti-human immunodeficiency virus levels in the cerebrospinal fluid were negative.\nAn occipital craniotomy and biopsy was performed using the guidance of neuronavigation. In the operative field, there was a reddish color change of the cortex and the thickened arachnoid membrane had a yellowish color change (). There was no definitive mass lesion. By using grasping forcep, the biopsy was done in the yellowish white matter. The biopsy showed many inflammatory cells containing some hyphae with the positive periodic acid-shiff stain (). The pathology result showed a brain abscess caused by fungal infection that had the morphologically of aspergillus. Amphotericin B (50 mg/day) therapy was immediately started after the biopsy confirmation, but there were swelling, and skin eruptions at injection site, and fever. On the 3rd day of treatment, the antifungal agent was changed to ambisome (3 mg/kg/day). After 6 days, the serum creatinine level became elevated to 1.9 mg/dL and the antifungal agent was changed with voriconazole (400 mg/day). Voriconazole therapy was maintained for 3 months. The subjective visual symptom improved. There was no recurrence noted at the one year follow up MRI, but the remaining focal enhanced lesions were visible in the right temporal and occipital area ().