PMC9901442_01
Skin lesions presented with a 1x1 cm dark red a round-like on the right upper arm (A) and a 10x5 cm irregularly shaped dark red on the left inner forearm (B), without protruding from the skin surface, without pruritus, pain or desquamation.
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Other physical examinations revealed dark red lesions (about 1x1 cm and 10x5 cm) located on the right and left forearms, respectively (Figures 1A and B).
(A-D) Brain MRI on day 5 of onset revealed multiple enhanced lesions on the bilateral perimesencephalic cistern, sylvian fissure and cerebral longitudinal fissure and its peripheral cerebral cortex, as well as the frontal lobe and parietal lobe; (E-H) MRI of the thoracic segment on day 14 of onset revealed the 2-4, 12 thoracic medullary enlargements, with longer T1, T2 signals, and spinal cord membrane thickening with cystic image, which were enhanced.
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Brain MRI showed lesions enhanced, including the bilateral perimesencephalic cistern, sylvian fissure and cerebral longitudinal fissure and its peripheral cerebral cortex, as well as the frontal lobe and parietal lobe (Figure 2A-D). MRI of the thoracic segment revealed that the spinal cord with patchy longer T2 signals, which were vaguely enhanced (Figure 2E-H).
(A) Graphical timeline of drug administration. (B) Results of next-generation sequencing in cerebrospinal fluid, B. mandrillaris genome coverage map.
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The diagnosis of CNS infection led to combined therapy with acyclovir (500 mg, BID, ivgtt), ceftriaxone sodium (2 g, QD, ivgtt), foscarnet sodium (3g, Q12H), and dexamethasone (10 mg, QD) (Figure 3A).    Mild change in CSF on day 15 post-onset compared to the previous (Table 1), fortunately, a second NGS identified B. mandrillaris (Figures 3B).