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CASE REPORT
Year : 2004  |  Volume : 22  |  Issue : 3  |  Page : 193-195
 

Brain abscess due to cladophialophora bantiana


Departments of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029, Karnataka, India

Date of Submission22-Feb-2004
Date of Acceptance05-Mar-2004

Correspondence Address:
Departments of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029, Karnataka, India

 ~ Abstract 

Cladophialophora bantiana (Xylohypha bantiana) is a dematiaceous fungus with distinct neurotropism. CNS phaeohyphomycosis due to C. bantiana is an uncommon infectious condition and is associated with high mortality. We report this rare clinical entity in a 22-year-old male, presenting as brain abscess. Etiological diagnosis was made based on fungal culture and histopathological examination. Complete surgical resection of the lesion and treatment with antifungal agents could not save the patient from this frequently fatal infection.

How to cite this article:
Jayakeerthi S R, Dias M, Nagarathna S, Anandh B, Mahadevan A, Chandramuki A. Brain abscess due to cladophialophora bantiana. Indian J Med Microbiol 2004;22:193-5


How to cite this URL:
Jayakeerthi S R, Dias M, Nagarathna S, Anandh B, Mahadevan A, Chandramuki A. Brain abscess due to cladophialophora bantiana. Indian J Med Microbiol [serial online] 2004 [cited 2019 Dec 9];22:193-5. Available from: http://www.ijmm.org/text.asp?2004/22/3/193/11219


Phaeohyphomycosis is a heterogeneous group of fungal disease characterized by dematiaceous (darkly pigmented) hyphal forms in tissue. Dematiaceous fungi, common cause of skin infections in humans, very rarely cause systemic illness. Xylohypha bantiana, a dematiaceous fungus with “distinct neurotropism”, is the most commonly described etiological agent of CNS phaeohyphomycosis in world literature.[1] The first report of this clinical entity in India was by Bagchi et al,[2] where the diagnosis was made based on histopathological findings with out evidence of culture. Dastur et al[3] from Mumbai described the first culture proven case in India.

 ~ Case Report Top

A 22-year-old male, computer trainee from Tamil Nadu was admitted to our hospital under neurological services in June 2002. He was referred from a peripheral hospital where, he underwent craniotomy and biopsy of the left side posterior frontal lesion that had caused severe diffuse headache, deviated angle of mouth, slurring of speech and weakness in the right upper and lower limbs of 15 days duration.
On clinical examination, patient was conscious, oriented and afebrile with all the vital parameters being normal. Examination of ocular fundus revealed bilateral papilloedema. Patient had motor aphasia, right upper motor neuron facial palsy and left hemiplegia. He was not a known smoker, alcoholic or I.V drug abuser. Complete haemogram, blood chemistry and serum electrolyte levels were normal. Patient was seronegative for HIV-1 and HIV-2 by ELISA. His CD4, CD8 and CD3 counts were 383 cells/mL, 264/mL and 643/mL respectively. The CD4:CD8 ratio was 1.45.
Cranial CT scan showed two ring-enhancing lesions in the left posterior frontal region with severe perilesional oedema along with brain bulging through the craniotomy defect [Figure - 1]. Ultrasound guided aspiration from this lesion yielded, a heavily blood mixed purulent material. It was inoculated into Sabouraud dextrose agar (SDA) and incubated at room temperature and 370 C. Wet mount preparations in sterile saline, Gram stained and Ziehl-Neelsen (ZN) stained smears were examined under microscope.
Microscopic examination of the wet mount preparation revealed numerous pus cells, red blood cells and fungal hyphae measuring about 2-3 mm in diameter. Hyphae were septate and darkly pigmented with many conidia attached to the sides and lying free. Conidia were elliptical, measuring about 2-3 mm x 6 mm [Figure:2]a. Gram and ZN smears did not reveal any bacteria or acid fast structures. On day five of incubation, few gray colonies were seen on SDA. Colonies turned olive-gray to brown by 14 days. Lacto phenol cotton blue preparations made from this fungal growth revealed septate, darkly pigmented hyphae with chains of elliptical conidia attached [Figure:2]b. No pigmented scar was noticed on the conidia. The isolate could be grown at 420C, a feature that differentiates C. bantiana from other morphologically similar saprophytic fungi.[4]
Histological examination of the thick walled abscess cavity revealed inner zone of necrotic material and outer zone of vascular granulation tissue, surrounded by gliosed brain parenchyma. The abscess wall had dense plasma cells, lymphocytes and foamy histiocytic infiltrations along with a few granulomas. Within the inflammatory infiltrate and giant cells, numerous delicate elongated thin branching, septate hyphae with disjunctors were seen lying in groups, scattered singly or stuffed in giant cells. The fungal hyphae revealed golden brown colour characteristic of chromomycosis.
Patient was started on oral fluconazole (200 mg/d), flucytosine (500 mg/d) and injection amphotericin-B (1.2 gm/d) along with anti oedema measures. Excision of the fungal abscess was carried out once, the repeat CT scan revealed decreased oedema and brain bulge. Postoperative cranial CT scan confirmed complete excision of the abscess cavity. However, the patient lived only for five weeks post surgery and finally succumbed to the fungal infection complicated with a postoperative ventriculitis due to Staphylococcus aureus.

 ~ Discussion Top

Fungal infections of the CNS has seen a steep rise in numbers, largely, due to the advent of acquired immunodeficiency syndrome (AIDS), wide spread use of broad spectrum antibiotics, steroids and immunosuppressive drugs for a variety of conditions.[1] However, the dematiaceous fungal infections of the CNS continue to be uncommon. C. bantiana is the most commonly described dematiaceous fungus in the etiology of brain abscess. This fungus, of a considerable taxonomical confusion, has recently been accommodated under the genus Cladophialophora, separated from the saprophytic Cladosporium species by having poorly differentiated conidiophores and unpigmented scars.[4]
Most infections occur in second and third decade of life, with the youngest patient reported being a six day old neonate.[5] CNS infection in a six month old boy[6] was the youngest case documented in literature till recently. Young males are most frequently involved group. No predilection for race or geographic location is observed. C. bantiana, in contrast to other CNS affecting molds like Aspergillus spp. and Zygomycetes, predominantly involves individuals with no obvious predisposing factors. Involvement of immunocompetent hosts is very typical of C. bantiana infections, though there are a few reports of infection in immuno-compromised individuals.[7]
CNS cladosporiosis generally manifests as brain abscess, with few exceptional presentations such as chronic meningitis.[8] Earlier two cases that have been reported from our institution[9] presented as meningoencephalitis with extensive areas of haemorrhagic infarctions of frontoparietal lobes. Chronic headache is the commonest symptom. Other symptoms include, fever, seizures, lethargy, meningismus and focal neurological deficits. CT scan of the cranium often reveals unilateral well circumscribed mass lesion, most frequently located in the frontal lobe. Other reported anatomical sites involved include, parietal lobe, occipital lobe, cerebellum and medulla oblongata. There is no initial clinical or laboratory feature that yields a preoperative aetiological diagnosis of this condition. But once the material from the lesion is collected, a simple wet mount preparation could enable identification of the fungus. Growth of the fungus in vitro is essential for establishing specific aetiological diagnosis.
High mortality among the reported cases is mainly due to a delay in surgical intervention and treatment with less effective anti-fungal agents like amphotericin B. In the present case, much of the precious time was lost with initial conservative management. By the time, an aetiological diagnosis was made the lesion was no longer well localized. Though, the postoperative CT scan revealed complete surgical removal of the lesion, microscopic residue of the fungal elements cannot be ruled out. Delay in surgery along with probable postoperative microscopic remnants of the fungus complicated with postoperative bacterial infection made the patient to succumb to this frequently fatal condition. This re-emphasises the importance of an early complete surgical resection of the lesion/s along with flucytosine therapy that has proved life saving in some of the reported cases.[10] 

 ~ References Top

1.Sepkowitz K, Armstrong D. Space occupying fungal lesions. In: WM Scheld, RJ Whitley and DT Durack (ed). Infections of the Central Nervous System, 2nd edn, Philadelphia: Lippincott-Raven Publishers, 1997:741-762.  Back to cited text no. 1    
2.Bagchi A, Aikat BK, Baura D. Granulomatous lesion of the Brain produced by Cladosporium trichoides. J Ind Med Ass 1962;38:602.  Back to cited text no. 2    
3.Dastur HM, Chaukar AP, Rebello MD. Cerebral chromoblastomycosis due to Cladosporium trichoides (bantianum)-Part 1. Neurol Ind 1966;14:1-5.  Back to cited text no. 3    
4.Dixon DM, Walsh TJ, Merz WG, McGinnis MR. Infection due to Xylohypha bantiana (Cladosporium trichoides). Rev Infect Dis 1989;2(4):515-25.   Back to cited text no. 4    
5.Banerjee TK, Patwari AK, Dutta R, Anand VK, Chabra A. Cladosporium bantianum meningitis in a neonate. Indian J Pedtr 2002;69(8):721-723.  Back to cited text no. 5    
6.Sandhyamani S, Bhatia R, Mohapatra LN, Roy S. Cerebral Cladosporiosis. Surg Neurol 1981;15(6):431-434.   Back to cited text no. 6    
7.Gupta SK, Manjunath Prasad KS, Sharma BS, Khosla VK, Kak VK, Minz M, Sakhuja VK. Brain abscess in renal transplant recipients: report of three cases. Surg Neurol 1997;48:284-287.  Back to cited text no. 7    
8.Bennett JE, Bonner H, Jennings AE, Lopez RI. Chronic meningitis caused by Cladosporium trichoides. Am J Clin Pathol 1973;59(3):398-407.  Back to cited text no. 8    
9.Chandramuki A, Ramadevi MG, Shankar SK. Cerebral cladosporiosis- A neuropathological and microbiological study. Clin Neurol Neurosurg 1983;85(4): 245-253.  Back to cited text no. 9    
10.Vyas MCR, Joshi YR, Bhargava N, Joshi KR, Tanwar RK. Cerebral Chromoblastomycosis- A rare case report of cerebral abscess and brief review of literature. Indian J Pathol Microbiol 2000;43(1):81-85.  Back to cited text no. 10    
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