J Korean Neurosurg Soc.  2015 Jan;57(1):50-53. 10.3340/jkns.2015.57.1.50.

Cryptococcal Brainstem Abscess Mimicking Brain Tumors in an Immunocompetent Patient

• Hur JH
• Kim JH
• Park SW
• Cho KG

• KMID: 2067091
• DOI: http://doi.org/10.3340/jkns.2015.57.1.50

Abstract

Usually fungal infections caused by opportunistic and pathogenic fungi had been an important cause of morbidity and mortality among immunocompromised patients. However clinical data and investigations for immunocompetent pathogenic fungal infections had been rare and neglected into clinical studies. Especially Cryptococcal brainstem abscess cases mimicking brain tumors were also much more rare. So we report this unusual case. This 47-year-old man presented with a history of progressively worsening headache and nausea for 1 month and several days of vomituritions before admission. Neurological and laboratory examinations performed demonstrated no abnormal findings. Previously he was healthy and did not have any significant medical illnesses. A CT and MRI scan revealed enhancing 1.8x1.7x2.0 cm mass lesion in the left pons having central necrosis and peripheral edema compressing the fourth ventricle. And also positron emission tomogram scan demonstrated a hot uptake of fluoro-deoxy-glucose on the brainstem lesion without any evidences of systemic metastasis. Gross total mass resection was achieved with lateral suboccipital approach with neuronavigation system. Postoperatively he recovered without any neurological deficits. Pathologic report confirmed Cryptococcus neoformans and he was successively treated with antifungal medications. This is a previously unreported rare case of brainstem Cryptococcal abscess mimicking brain tumors in immunocompetent host without having any apparent typical meningeal symptoms and signs with resultant good neurosurgical recovery.

Keyword

Brainstem abscess mimicking brain tumors; Cryptococcus; Immunocompetent

MeSH Terms

Abscess*
Brain Neoplasms*
Brain Stem*
Cryptococcus
Cryptococcus neoformans
Edema
Electrons
Fourth Ventricle
Fungi
Headache
Humans
Immunocompromised Host
Magnetic Resonance Imaging
Middle Aged
Mortality
Nausea
Necrosis
Neoplasm Metastasis
Neuronavigation
Pons

Figure

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  Fig. 1 A CT scan reveals enhancing mass lesion with central necrosis and peripheral edema in the left pons compressing the fourth ventricle.

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  Fig. 2 Subsequent simple, diffusion, and perfusion MRI images demonstrate a rim-enhancing about 1.8×1.7×2.0 cm sized, highly perfusing mass lesion with heterogeneous low or iso-signal intensity.

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  Fig. 3 PET scans of the whole body comprising brainstem demonstrate a hot uptake of FDG on the brainstem lesion without having any evidences of systemic metastasis. PET : positron emission tomogram, FDG : fluoro-deoxy-glucose.

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  Fig. 4 Gross total mass resection achieved with lateral suboccipital approach with the help of neuronavigation system and SSEP monitoring. SSEP : somatosensory evoked potential.

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  Fig. 5 A : Granulomatous inflammations with Cryptococcus yeasts in the macrophages and multinucleated giant cells (H&E, ×200). B : Many Cryp-tococcus yeasts capsules stained with mucicarmine (×200). C : Methenamine silver stains reveal numerous Cryptococcus yeasts (×200).

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