PMC7471810_01
T2-weighted sequences of the brain MRI demonstrating cerebral abscesses and associated edema. Top row: initial presentation; middle row: repeat imaging, 3 weeks after initial presentation; bottom row: final imaging, 2 months after initial presentation.
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Brain MRI showed 3 distinct left temporal and parietal lobe abscesses with significant edema (Figure 1), for which he was started on high-dose dexamethasone 4 mg four times daily. Repeat imaging revealed decrease in the size of the brain abscesses (Figure 1) and of the pulmonary nodule with central cavitation (Figure 2). Brain MRI showed significant decrease in the size of previous abscesses, but also many new infarcts (Figure 1).
Chest CT. (a) pulmonary nodule on initial presentation; (b) pulmonary nodule on repeat imaging, 3 weeks after initial presentation.
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Chest CT revealed a pulmonary nodule (Figure 2). Repeat imaging revealed decrease in the size of the brain abscesses (Figure 1) and of the pulmonary nodule with central cavitation (Figure 2).
(a, b) Chest CT: invasive pulmonary aspergillosis. Chest CT findings, 2 months after initial presentation.
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Chest CT showed multiple lung masses with cavitation, consistent with new abscesses (Figure 3).
(a-c) Autopsy: invasive pulmonary aspergillosis. Left: macroscopic appearance of congested lung with infarcted and hemorrhagic areas; middle: hematoxylin-eosin (H&E) stain; right: Gomori methenamine silver (GMS) stain.
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Hyphal morphology was consistent with Aspergillus species (septate, narrow-angled, Figure 4).
Autopsy: heart and kidneys. Cardiac (a) and renal (b) mucormycosis, H&E and GMS (small panel) stains.
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Lung cultures were positive for Aspergillus fumigatus. (2) Acute IMI in both heart ventricles, with wide-angled, aseptate hyphae, consistent with mucormycosis (Figure 5); molecular studies (28 s/internal transcriber sequence (ITS) RNA identification, University of Washington, Seattle) came back positive for Lichtheimia corymbifera. (3) Cervical, mediastinal lymph node, thyroid gland, and left kidney (Figure 5) IMI. (4) Cerebral abscesses of the left temporal and parietal lobes with fungal organisms in the blood vessels and brain parenchyma, consistent with mucorales (Figure 6), and filamentous organisms identified with GMS/FITE stains, consistent with Nocardia (Figure 7).
Autopsy: cerebral mucormycosis. Macroscopic appearance of temporal lobe abscess (a); abundant aseptate, wide-angled hyphae in blood vessels ((b), H&E stain) and brain parenchyma ((c), GMS stain).
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Lung cultures were positive for Aspergillus fumigatus. (2) Acute IMI in both heart ventricles, with wide-angled, aseptate hyphae, consistent with mucormycosis (Figure 5); molecular studies (28 s/internal transcriber sequence (ITS) RNA identification, University of Washington, Seattle) came back positive for Lichtheimia corymbifera. (3) Cervical, mediastinal lymph node, thyroid gland, and left kidney (Figure 5) IMI. (4) Cerebral abscesses of the left temporal and parietal lobes with fungal organisms in the blood vessels and brain parenchyma, consistent with mucorales (Figure 6), and filamentous organisms identified with GMS/FITE stains, consistent with Nocardia (Figure 7).
Autopsy: cerebral nocardiosis. GMS (a) and FITE (b) stains.
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Lung cultures were positive for Aspergillus fumigatus. (2) Acute IMI in both heart ventricles, with wide-angled, aseptate hyphae, consistent with mucormycosis (Figure 5); molecular studies (28 s/internal transcriber sequence (ITS) RNA identification, University of Washington, Seattle) came back positive for Lichtheimia corymbifera. (3) Cervical, mediastinal lymph node, thyroid gland, and left kidney (Figure 5) IMI. (4) Cerebral abscesses of the left temporal and parietal lobes with fungal organisms in the blood vessels and brain parenchyma, consistent with mucorales (Figure 6), and filamentous organisms identified with GMS/FITE stains, consistent with Nocardia (Figure 7).