Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Thoracic spinal cord intramedullary aspergillus invasion and abscess Addason F. McCaslin, Rishi R. Lall ⇑, Albert P. Wong, Rohan R. Lall, Patrick A. Sugrue, Tyler R. Koski Northwestern University Feinberg School of Medicine, Department of Neurological Surgery, NMH/Arkes Family Pavilion Suite 2210, 676 N Saint Clair Street, Chicago, IL 60611, USA
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Article history: Received 21 February 2014 Accepted 21 April 2014 Available online xxxx Keywords: Abscess Central nervous system vasculitis Fungi Intramedullary aspergilloma Neuroaspergillosis Precursor cell lymphoblastic leukemialymphoma
a b s t r a c t Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12–L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases. Ó 2014 Published by Elsevier Ltd.
1. Introduction Invasive central nervous system (CNS) aspergillosis is a rare form of fungal infection that may arise in immunocompromised patients [1–3]. Intracranial disease occurs most commonly and is rapidly fatal without treatment [1]. Spinal aspergillosis is more indolent, but far rarer and typically develops from contiguous vertebral osteomyelitis or systemic infection [3]. Reports in the literature have catalogued multiple patients with epidural or intradural extramedullary abscesses, but never with intramedullary involvement [2,3]. Here we describe to our knowledge the first reported case of an intramedullary spinal cord aspergillus abscess resulting from contiguous spread of infection, and highlight the need for prompt identification and treatment to prevent the rapidly fatal sequelae of intracranial extension. 2. Case report A 19-year-old woman with a history of active acute lymphoblastic leukemia presented to an outside hospital with several weeks of progressive bilateral lower extremity weakness and fevers. MRI of the lumbar spine showed vertebral discitis and osteomyelitis from T12–L1 with a small epidural fluid collection. ⇑ Corresponding author. Tel.: +1 312 695 6200; fax: +1 312 695 0225. E-mail address: [email protected] (R.R. Lall).
Targeted bone biopsy and abscess cultures showed weak growth of aspergillus believed to be contamination. She was discharged on ceftriaxone but returned to an outside hospital several weeks later with fever, hypotension, and increased leg weakness. Lumbar puncture showed red blood cells 20 cells/lL (normal: 0 cells/lL), white blood cells 1459 cells/lL (normal:
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Thoracic spinal cord intramedullary aspergillus invasion and abscess Addason F. McCaslin, Rishi R. Lall ⇑, Albert P. Wong, Rohan R. Lall, Patrick A. Sugrue, Tyler R. Koski Northwestern University Feinberg School of Medicine, Department of Neurological Surgery, NMH/Arkes Family Pavilion Suite 2210, 676 N Saint Clair Street, Chicago, IL 60611, USA
a r t i c l e
i n f o
Article history: Received 21 February 2014 Accepted 21 April 2014 Available online xxxx Keywords: Abscess Central nervous system vasculitis Fungi Intramedullary aspergilloma Neuroaspergillosis Precursor cell lymphoblastic leukemialymphoma
a b s t r a c t Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12–L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases. Ó 2014 Published by Elsevier Ltd.
1. Introduction Invasive central nervous system (CNS) aspergillosis is a rare form of fungal infection that may arise in immunocompromised patients [1–3]. Intracranial disease occurs most commonly and is rapidly fatal without treatment [1]. Spinal aspergillosis is more indolent, but far rarer and typically develops from contiguous vertebral osteomyelitis or systemic infection [3]. Reports in the literature have catalogued multiple patients with epidural or intradural extramedullary abscesses, but never with intramedullary involvement [2,3]. Here we describe to our knowledge the first reported case of an intramedullary spinal cord aspergillus abscess resulting from contiguous spread of infection, and highlight the need for prompt identification and treatment to prevent the rapidly fatal sequelae of intracranial extension. 2. Case report A 19-year-old woman with a history of active acute lymphoblastic leukemia presented to an outside hospital with several weeks of progressive bilateral lower extremity weakness and fevers. MRI of the lumbar spine showed vertebral discitis and osteomyelitis from T12–L1 with a small epidural fluid collection. ⇑ Corresponding author. Tel.: +1 312 695 6200; fax: +1 312 695 0225. E-mail address: [email protected] (R.R. Lall).
Targeted bone biopsy and abscess cultures showed weak growth of aspergillus believed to be contamination. She was discharged on ceftriaxone but returned to an outside hospital several weeks later with fever, hypotension, and increased leg weakness. Lumbar puncture showed red blood cells 20 cells/lL (normal: 0 cells/lL), white blood cells 1459 cells/lL (normal:
