PMC5402337_01
Magnetic resonance imaging demonstrated rim-enhancing 2 cm cystic lesions in the bilateral frontal lobes with associated cerebral edema
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F1
Neurological exam on admission was normal, however, initial imaging of the brain revealed bilateral mesial frontal ring-enhancing lesions most consistent with abscesses [Figure 1].
Fontana stain on brain aspirate revealed septated hyphae (a). Cultures on potato flake agar (day 6) grew black- gray velvety colony (b). Lactophenol cotton blue preparation revealed long, sparsely branched conidiophores producing long chains of terminal and lateral oval conidia (c)
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F2
Pus was retrieved from both lesions which on gram stain did not reveal bacterial but instead showed septated hyphae typical of fungi. amphotericin B intravenously was then added for coverage [Figure 2].
Serial MRI T1 sequence with contrast showing the disease course over time. (Top Left) after failure of antibacterial therapy. (Top Middle) After stereotactic aspiration. (Top Right) After surgical resection and placement of bilateral Ommaya reservoirs. (Bottom Left) Progression of lesion after stopping outpatient anti-fungal therapy. (Bottom Middle) Surveillance scan showing stability of lesion while patient on therapy. (Bottom Right) Last scan showing stability of lesion while the patient was off therapy for 3 years
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F3
Cultures later confirmed black mold (dark colored largely unbranched hyphae) C. bantiana species [Figure 3]. Later, he was transitioned to weekly aspiration/injections that were continued for another 5 months, during which findings on periodic MRI remained stable [Figure 3].
Change in the abscesses' size over time based on serial brain MRIs; it also shows the timeline for medical treatment, as well as surgical interventions
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F4
At the time of writing this article, over 3 years from initial diagnosis, the patient remains off all antifungals and no longer receives intracavitary treatment [Figure 4].