title: Aspergillus Terreus Brain Abscess Complicated by Tension Pneumocephalus in a Patient with Angiosarcoma.
abstract: BACKGROUND Aspergillus terreus is an evolving opportunistic pathogen, and patients with A. terreus often have poor outcomes due to its intrinsic resistance to several systemic antifungal agents. Here we present a unique case of intracranial abscesses of A. terreus in a patient with recurrent angiosarcoma, complicated by development of tension pneumocephalus. CASE REPORT A 67-year old gentleman with history of scalp angiosarcoma with wide excision two years prior presented to the hospital for left arm clumsiness, altered mental status, and low-grade fever. Staphylococcus aureus and Proteus mirabilis bacteremia was detected, and Computed Tomography (CT) of the head showed right frontal lobe abscesses. He was started on steroids, intravenous vancomycin and cefepime, and was eventually discharged. He presented to the hospital again due to persistent and worsening symptoms. MRI showed progression of the brain lesions, and surgical biopsy and culture of lesions revealed A. terreus and gram-positive cocci. He was started on trimethroprim/sulfamethoxazole and voriconazole and symptoms improved. On post-op day four, he acutely decompensated with total loss of left arm strength; MRI demonstrated tension pneumocephalus. Conservative management was undertaken with continuous supplemental oxygen. Serial x-ray imaging over the next week demonstrated resolution of the pneumocephalus, and the patient was able to regain all proximal lower and upper extremity strength. CONCLUSIONS Never before has a case of A. terreus been associated with angiosarcoma or tension pneumocephalus in the literature. Proper identification and prompt diagnosis of species is crucial in the immunocompromised patient. Tension pneumocephalus should be included in the differential diagnosis of nontraumatic hemiparesis for emergent evaluation and management.
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Thejal
authors.initials: T
authors.lastname: Srikumar
authors.affiliation: Department of Internal Hospital Medicine, Moffitt Cancer Center, Tampa, FL, USA.
authors.forename: Smitha
authors.initials: S
authors.lastname: Pabbathi
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
authors.forename: Jorge
authors.initials: J
authors.lastname: Fernandez
authors.affiliation: Department of Internal Hospital Medicine, Moffitt Cancer Center, Tampa, FL, USA.
authors.forename: Sowmya
authors.initials: S
authors.lastname: Nanjappa
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001228:Aspergillosis / Q000150:complications* / Q000188:drug therapy; D001230:Aspergillus / Q000302:isolation & purification*; D016470:Bacteremia / Q000188:drug therapy / Q000382:microbiology*; D001922:Brain Abscess / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D000077723:Cefepime; D002511:Cephalosporins / Q000627:therapeutic use; D018450:Disease Progression; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005938:Glucocorticoids / Q000627:therapeutic use; D006394:Hemangiosarcoma / Q000150:complications*; D006801:Humans; D016867:Immunocompromised Host; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D011007:Pneumocephalus / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D011513:Proteus mirabilis / Q000302:isolation & purification; D012878:Skin Neoplasms / Q000150:complications*; D013211:Staphylococcus aureus / Q000302:isolation & purification*; D013419:Sulfamethizole / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D014295:Trimethoprim / Q000627:therapeutic use; D014640:Vancomycin / Q000627:therapeutic use; D065819:Voriconazole / Q000627:therapeutic use; D000096926:Benzenesulfonamides
chemical_list: D000900:Anti-Bacterial Agents; D000077723:Cefepime; D002511:Cephalosporins; D004338:Drug Combinations; D005938:Glucocorticoids; D013419:Sulfamethizole; D014295:Trimethoprim; D014640:Vancomycin; D065819:Voriconazole; C029078:trimethoprim sulfamethizole; D000096926:Benzenesulfonamides