title: Curvularia abscess of the brainstem.
abstract: OBJECTIVE
  To present a unique case of a brainstem Curvularia fungal infection and review the diagnosis and management of this rare phenomenon.
  
  
  METHODS
  A 33-year-old immunocompetent African American male presented with 2 weeks of headache, nausea, and vomiting in a setting of a recent 20-lb weight loss. Neurological examination was positive for multiple cranial nerve palsies, hemisensory loss, and gait instability. Magnetic resonance imaging demonstrated an enhancing medullary lesion.
  
  
  RESULTS
  Metastatic and infectious workup revealed a left lung lesion, which on subsequent biopsy was positive for a granuloma yielding no further clues to the etiology of the brainstem lesion. On surgical exploration of the cranial lesion, a puss-filed, encapsulated lesion was encountered that was tightly adherent to the brainstem. Intraoperative biopsy of the lesion capsule was initially negative but on postoperative day 9, fungal hyphae were encountered identified on morphology as Curvularia species. The patient was started on triple antifungal therapy but necessitated a second surgery for lesion debulking and drainage. The patient was discharged home 10 weeks after initial presentation. At the 13-months follow-up the patient is doing very well and his neurological examination continues to improve.
  
  
  CONCLUSIONS
  This is the first reported case of a brainstem Curvularia infection. This case highlights the importance of an aggressive surgical and antibiotic therapy in the treatment of central nervous system Curvularia infections. There appears to be a strong relationship between heavy marijuana use and Curvularia infection, producing lung granulomas that may extend to other organs such as the central nervous system of immunocompetent patients.
authors.affiliation: Department of Neurosurgery, Mount Sinai School of Medicine, New York City, New York, USA. Electronic address: skovrlj.branko@gmail.com.
authors.forename: Branko
authors.initials: B
authors.lastname: Skovrlj
authors.affiliation: School of Medicine, Karolinska Institutet, Hagalund, Sweden.
authors.forename: Maryam
authors.initials: M
authors.lastname: Haghighi
authors.affiliation: Department of Pathology, James J. Peters VA Medical Center, Bronx, New York, USA.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Smethurst
authors.affiliation: Department of Neurosurgery, Mount Sinai School of Medicine, New York City, New York, USA.
authors.forename: John
authors.initials: J
authors.lastname: Caridi
authors.affiliation: Department of Neurosurgery, Mount Sinai School of Medicine, New York City, New York, USA.
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Bederson
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use; D001203:Ascomycota; D001922:Brain Abscess / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery*; D001933:Brain Stem / Q000473:pathology / Q000601:surgery*; D020314:Central Nervous System Fungal Infections / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery*; D003389:Cranial Nerve Diseases / Q000188:drug therapy / Q000473:pathology / Q000601:surgery; D006261:Headache / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008881:Migraine Disorders / Q000209:etiology; D009422:Nervous System Diseases / Q000209:etiology; D009460:Neurologic Examination; D010292:Paresthesia / Q000209:etiology; D011743:Pyrimidines / Q000627:therapeutic use; D016896:Treatment Outcome; D014230:Triazoles / Q000627:therapeutic use; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D011743:Pyrimidines; D014230:Triazoles; D065819:Voriconazole
keywords: Brainstem; Curvularia abscess; Fungal central nervous system infection; Phaeohyphomycosis