Neurochirurgia 19 (1976), 126-129 © Georg Thiemc Verlag Stuttgart
Massive Cerebellar Abscess Due to Candida Albicans J. Holyst, A. Majewski, S. Tyszkiewicz Departments of Neurosurgery and Pathology Hospital, Walbrzych, Poland
A case of a previously healthy 51-year-old man, who was diagnosed clinically as having a posterior cranial fossa tumour. At operation this proved to be an abscess which was radically removed. Histological investigations showed the presence of a fungus which was identified as Candida albicans. Key-words: Mycotic infection - Candida albicans - Cerebellar abscess Zusammenfassung Bei einem 51jährigen bis dahin gesunden Mann wurde klinisch die Diagnose eines Tumors der hinteren Schädelgrube diagnostiziert, der sich bei der Operation als ein radikal zu entfernender Abszeß erwies. Die histologische Untersuchung erlaubte den Nachweis eines Pilzes, der als Candida albicans identifiziert wurde.
Although cerebral Candida infection was described by Zenker in 1861 it is still relatively uncommon in spite of the frequency of pulmonary involvement (DeVita, Vtz, Williams 1966, Eschwege 1958, Tetter, Klinworth, Hendry 1967, Recht 1973, Recht, Regele 1974, Luyendijk, Welman, Cormane 1959, Svolos, Nordenstam 1960). Prior to 1974 approximately 50 cases were collected, mostly associated with meningitis or meningo-encephalitis (Recht, Regele 1974) but abscess or granuloma of the brain was found rarely {Black 1970, Recht 1973, 1 scheme 1965). The exact diagnosis of cerebral candidiasis is difficult or even impossible during life (Fetter, Rlintworth, Hendry 1967). There are numerous reasons for this. Thus, during the first
stage there is an insidious onset with symptoms and signs often atypical and vague (Svolos, Nordenstam 1960). The following case concerns a huge cerebellar abscess secondary to fungous infection. The rarity of central nervous system involvement with Candida albicans has promted this report.
Case Report A 51-year-old man was admitted in October 1974. The past medical history was not relevant. His previous health was good with no history of anti-biotic or steroid therapy. During the previous two months there had been symptoms and signs suggesting the presence of a subtentorial space occupying lesion. He complained of increasing headaches especially in the occipital area, vertigo and vomiting. A few days before admission he became drowsy, apathetic and confused. His temperature was raised to 38° C. Examination: The patient was in a very poor condition, badly nourished, disorientated and unco-operative. He was unable to stand without support. His speech was slurred, coarse nystagmus on gaze to the right was prominent. Ophthalmoscopic examination showed bilateral papilledema. Babinskys sign was positive bilaterally. There was no neck stiffness and Kernig's sign was absent. The rest of the neurological examination was normal. Routine laboratory tests including examinations of the blood and urine were within normal limits. X-ray examinations of the chest and skull were normal.
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Summary
Massive Cerebellar Abscess Due to Candida Albicans
127
Central ventriculography with water-soluble contrast medium (Dimer-X) was performed in the theatre under monitor control. The aqueduct was slightly kinked, dilated and narrowed near the fourth ventricle which was pushed upward (Fig. 1). In the AP view there was marked dilatation of the third and lateral ventricles and displacement of the fourth ventricle from left to right.
Histological examination: The material stained with haematoxylin and eosin, Gram and Kligman contained mycelial colonies surrounded by necrotic and inflammatory tissue, with polymorphonucelar leucocytes, macrophages and giant multinucleated cells some of which enclosed yeast-like organisms. Fungal elements found were morphologically related to the group of Candida albicans, in its elongated and oval forms (Fig. 3).
Fig. 1: Intra-operative ventriculogram from the case of a left sided cerebellar abscess.
Fig. 2: Photograph of the intact specimen. Scale in millimetres.
Post-operative course: The patient made en uneventful recovery. The symptoms and signs of raised intracranial pressure disappeared. Treatment with amphotericin B was started. Within a few days he improved sufficiently to allow him to walk without help. The cerebrospinal fluid pressure was normal and it contained 120 mgm% of protein and only 27 white cells. Blood and cerebrospinal fluid cultures were negative. Two weeks later despite the amphotericin therapy the patient deteriorated progressively, became drowsy and developed a stiff neck. The white cells in the spinal fluid were above
Fig. 3: Photomicrograph of the abscess. In the centre: Candida albicans with giant multinucleated cells. Upper: the zone of focal necrosis. Lower: chronic granulomatous inflammatory changes. Haematoxylin and eosin, X 100.
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Operation: With the patient in the sitting position sub-occipital craniectomy was performed. The cortex and arachnoid on the left side were adherent to the dura. The left hemisphere was enlarged and its surface showed a greyish-dark discolouration near the midline. The hemisphere was needled and approximately 2 ml of pus were recovered. After incision of the cortex the visible mass, about 5 cm in diameter was separated from the surrounding tissue and completely removed (Fig. 2). Section of the 'tumour' demonstrated that it was an abscess.
]• Holyst, A. Majewski, S. Tyszkiewicz
100 per c.mm. He died of respiratory complications. Autopsy findings: The brain was oedematous with basilar leptomeningitis. At the base of the brain in the region of the pons there were five foci of Candida from 3 to 5 mm in diameter (Fig. 4). No other lesions were encountered in the posterior fossa, not even in the operation field. The sections through the cerebral hemispheres revealed two small abscesses in the white matter near the frontal horn of the right lateral ventricle with which they communicated. The dilated ventricles showed ependymal proliferations with necrotic material and choroid plexus changes which were identified as Candidiasis. The lungs contained small, widespread foci of candidiasis. There was no evidence of fungi in other organs.
Discussion The case deserves particular attention because of its course and the neurological symptoms and signs suggesting the presence of a space-occupying lesion in the posterior fossa. At operation an abscess was found. It was a complete surprise when histological examination showed that the abscess was due to Candida albicans. The route of spread to the central nervous system is usually by way of the blood stream. It must be presumed that the fungal lesion found in the lungs acted as the source of infection for the cerebellar abscess. Candidiasis is the most acutely fatal fungal infection known in man (De Vita, Utz,
Fig. 4: Photograph of the base of the brain with foci of candidiasis on the pons. Williams 1966, Eschwege 1958, Kecht, Regele 1974). The prognosis in cerebral candidiasis varies, depending on the nature and site of the infection (Black 1970). In patients with meningitis Amphotericin B is the most effective therapeutic agent (DeVita, Utz, Williams 1966, Fetter, Klintworth, Hendry 1967). In contrast, in cases with brain abscess (Black 1970, Luyendijk, Welman, Cormane 1959) - as in our case - this treatment has been unsuccessful. As with other mycoses increased incidence of candidiasis of the central nervous system in recent series may be related to previous treatment with antibiotics or steroids {Kecht 1973, Kecht, Regele 1974). In our patient however, no antecedent condition, no predisposing medication or illnes could be found. According to Louria et al. the cause of the infection is not clear but it may be related in part to the virulence of the infecting strain of Candida albicans. The possibility of this condition must be borne in mind as a cause in the case described, despite the radical removal of the abscess and prolonged use of amphotericin B.
References 1 Black, J. T.: Cerebral candidiasis: case report of brain abscess secondary to Candida albicans and review of literature. J. Neurol. Neurosurg. Psychiat. 33 (1970) 864870 2 De Vita, V. T., /. P. Utz, T. Williams, P. P. Carbone: Candida meningitis. Arch, intern. Med. (Chicago) 117 (1966) 527-535 3 Eschwege, ].: Generalised moniliasis with localisation in
the brain. Arch. Neurol. Psychiat. (Chicago) 79 (1958) 250-263 4 fetter, B. F., G. K. Klintworth, W. S. Hendry: Mycoses of the central nervous system (Baltimore) 1967 Williams Wilkins Co., p. 53-62 5 Kecht, B.: Candida sepsis. Wien. klin. Wschr. 85 (1973) 549-553
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Doz. Dr. ]. Holyst, D,
moniliasis in the adult. Medicine (Baltimore) 41 (1962) 307-337 9 Svolos, D., A. Nordenstam: Chronic localised meningoencephalitis due to Candida albicans. Zbl. Neurochir. 20 (1960) 287-294 10 Tscheme, G. F.: Über zerebrale Manifestationen von Mycosen. Wien. Z. Nervenhk. 22 (1965) 247-259 '.rtment of Neurosurgery, Hospital 58-309, Walbrzych, Poland
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6 Kecht, B., H. Regele: Candidiasis des Zentralnervensystems. Wien. med. Wschr. 124 (1974) 407-409 7 Luyendijk, D. W., A. J. Welman, R. H. Cormane: Candidiasis met intracraniele lokalisatie (neurologische, mycologische en therapeutische aspecten). Ned. T. Geneeslc 103 (1959) 2320-2325 8 Louria, D. B., D. F. Stiff, B. Bennett: Disseminated
Massive Cerebellar Abscess Due to Candida Albicans J. Holyst, A. Majewski, S. Tyszkiewicz Departments of Neurosurgery and Pathology Hospital, Walbrzych, Poland
A case of a previously healthy 51-year-old man, who was diagnosed clinically as having a posterior cranial fossa tumour. At operation this proved to be an abscess which was radically removed. Histological investigations showed the presence of a fungus which was identified as Candida albicans. Key-words: Mycotic infection - Candida albicans - Cerebellar abscess Zusammenfassung Bei einem 51jährigen bis dahin gesunden Mann wurde klinisch die Diagnose eines Tumors der hinteren Schädelgrube diagnostiziert, der sich bei der Operation als ein radikal zu entfernender Abszeß erwies. Die histologische Untersuchung erlaubte den Nachweis eines Pilzes, der als Candida albicans identifiziert wurde.
Although cerebral Candida infection was described by Zenker in 1861 it is still relatively uncommon in spite of the frequency of pulmonary involvement (DeVita, Vtz, Williams 1966, Eschwege 1958, Tetter, Klinworth, Hendry 1967, Recht 1973, Recht, Regele 1974, Luyendijk, Welman, Cormane 1959, Svolos, Nordenstam 1960). Prior to 1974 approximately 50 cases were collected, mostly associated with meningitis or meningo-encephalitis (Recht, Regele 1974) but abscess or granuloma of the brain was found rarely {Black 1970, Recht 1973, 1 scheme 1965). The exact diagnosis of cerebral candidiasis is difficult or even impossible during life (Fetter, Rlintworth, Hendry 1967). There are numerous reasons for this. Thus, during the first
stage there is an insidious onset with symptoms and signs often atypical and vague (Svolos, Nordenstam 1960). The following case concerns a huge cerebellar abscess secondary to fungous infection. The rarity of central nervous system involvement with Candida albicans has promted this report.
Case Report A 51-year-old man was admitted in October 1974. The past medical history was not relevant. His previous health was good with no history of anti-biotic or steroid therapy. During the previous two months there had been symptoms and signs suggesting the presence of a subtentorial space occupying lesion. He complained of increasing headaches especially in the occipital area, vertigo and vomiting. A few days before admission he became drowsy, apathetic and confused. His temperature was raised to 38° C. Examination: The patient was in a very poor condition, badly nourished, disorientated and unco-operative. He was unable to stand without support. His speech was slurred, coarse nystagmus on gaze to the right was prominent. Ophthalmoscopic examination showed bilateral papilledema. Babinskys sign was positive bilaterally. There was no neck stiffness and Kernig's sign was absent. The rest of the neurological examination was normal. Routine laboratory tests including examinations of the blood and urine were within normal limits. X-ray examinations of the chest and skull were normal.
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Summary
Massive Cerebellar Abscess Due to Candida Albicans
127
Central ventriculography with water-soluble contrast medium (Dimer-X) was performed in the theatre under monitor control. The aqueduct was slightly kinked, dilated and narrowed near the fourth ventricle which was pushed upward (Fig. 1). In the AP view there was marked dilatation of the third and lateral ventricles and displacement of the fourth ventricle from left to right.
Histological examination: The material stained with haematoxylin and eosin, Gram and Kligman contained mycelial colonies surrounded by necrotic and inflammatory tissue, with polymorphonucelar leucocytes, macrophages and giant multinucleated cells some of which enclosed yeast-like organisms. Fungal elements found were morphologically related to the group of Candida albicans, in its elongated and oval forms (Fig. 3).
Fig. 1: Intra-operative ventriculogram from the case of a left sided cerebellar abscess.
Fig. 2: Photograph of the intact specimen. Scale in millimetres.
Post-operative course: The patient made en uneventful recovery. The symptoms and signs of raised intracranial pressure disappeared. Treatment with amphotericin B was started. Within a few days he improved sufficiently to allow him to walk without help. The cerebrospinal fluid pressure was normal and it contained 120 mgm% of protein and only 27 white cells. Blood and cerebrospinal fluid cultures were negative. Two weeks later despite the amphotericin therapy the patient deteriorated progressively, became drowsy and developed a stiff neck. The white cells in the spinal fluid were above
Fig. 3: Photomicrograph of the abscess. In the centre: Candida albicans with giant multinucleated cells. Upper: the zone of focal necrosis. Lower: chronic granulomatous inflammatory changes. Haematoxylin and eosin, X 100.
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Operation: With the patient in the sitting position sub-occipital craniectomy was performed. The cortex and arachnoid on the left side were adherent to the dura. The left hemisphere was enlarged and its surface showed a greyish-dark discolouration near the midline. The hemisphere was needled and approximately 2 ml of pus were recovered. After incision of the cortex the visible mass, about 5 cm in diameter was separated from the surrounding tissue and completely removed (Fig. 2). Section of the 'tumour' demonstrated that it was an abscess.
]• Holyst, A. Majewski, S. Tyszkiewicz
100 per c.mm. He died of respiratory complications. Autopsy findings: The brain was oedematous with basilar leptomeningitis. At the base of the brain in the region of the pons there were five foci of Candida from 3 to 5 mm in diameter (Fig. 4). No other lesions were encountered in the posterior fossa, not even in the operation field. The sections through the cerebral hemispheres revealed two small abscesses in the white matter near the frontal horn of the right lateral ventricle with which they communicated. The dilated ventricles showed ependymal proliferations with necrotic material and choroid plexus changes which were identified as Candidiasis. The lungs contained small, widespread foci of candidiasis. There was no evidence of fungi in other organs.
Discussion The case deserves particular attention because of its course and the neurological symptoms and signs suggesting the presence of a space-occupying lesion in the posterior fossa. At operation an abscess was found. It was a complete surprise when histological examination showed that the abscess was due to Candida albicans. The route of spread to the central nervous system is usually by way of the blood stream. It must be presumed that the fungal lesion found in the lungs acted as the source of infection for the cerebellar abscess. Candidiasis is the most acutely fatal fungal infection known in man (De Vita, Utz,
Fig. 4: Photograph of the base of the brain with foci of candidiasis on the pons. Williams 1966, Eschwege 1958, Kecht, Regele 1974). The prognosis in cerebral candidiasis varies, depending on the nature and site of the infection (Black 1970). In patients with meningitis Amphotericin B is the most effective therapeutic agent (DeVita, Utz, Williams 1966, Fetter, Klintworth, Hendry 1967). In contrast, in cases with brain abscess (Black 1970, Luyendijk, Welman, Cormane 1959) - as in our case - this treatment has been unsuccessful. As with other mycoses increased incidence of candidiasis of the central nervous system in recent series may be related to previous treatment with antibiotics or steroids {Kecht 1973, Kecht, Regele 1974). In our patient however, no antecedent condition, no predisposing medication or illnes could be found. According to Louria et al. the cause of the infection is not clear but it may be related in part to the virulence of the infecting strain of Candida albicans. The possibility of this condition must be borne in mind as a cause in the case described, despite the radical removal of the abscess and prolonged use of amphotericin B.
References 1 Black, J. T.: Cerebral candidiasis: case report of brain abscess secondary to Candida albicans and review of literature. J. Neurol. Neurosurg. Psychiat. 33 (1970) 864870 2 De Vita, V. T., /. P. Utz, T. Williams, P. P. Carbone: Candida meningitis. Arch, intern. Med. (Chicago) 117 (1966) 527-535 3 Eschwege, ].: Generalised moniliasis with localisation in
the brain. Arch. Neurol. Psychiat. (Chicago) 79 (1958) 250-263 4 fetter, B. F., G. K. Klintworth, W. S. Hendry: Mycoses of the central nervous system (Baltimore) 1967 Williams Wilkins Co., p. 53-62 5 Kecht, B.: Candida sepsis. Wien. klin. Wschr. 85 (1973) 549-553
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moniliasis in the adult. Medicine (Baltimore) 41 (1962) 307-337 9 Svolos, D., A. Nordenstam: Chronic localised meningoencephalitis due to Candida albicans. Zbl. Neurochir. 20 (1960) 287-294 10 Tscheme, G. F.: Über zerebrale Manifestationen von Mycosen. Wien. Z. Nervenhk. 22 (1965) 247-259 '.rtment of Neurosurgery, Hospital 58-309, Walbrzych, Poland
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6 Kecht, B., H. Regele: Candidiasis des Zentralnervensystems. Wien. med. Wschr. 124 (1974) 407-409 7 Luyendijk, D. W., A. J. Welman, R. H. Cormane: Candidiasis met intracraniele lokalisatie (neurologische, mycologische en therapeutische aspecten). Ned. T. Geneeslc 103 (1959) 2320-2325 8 Louria, D. B., D. F. Stiff, B. Bennett: Disseminated
