PMC8769430_01
Cerebral angiogram showing a right middle cerebral artery occlusion (A) and complete recanalization by mechanical thrombectomy (B). The retrieved thrombi were grayish and hard in consistency (C).
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F1
The modified thrombolysis in cerebral infarction (mTICI) scale score was 3 (Fig. 1A and 1B). They were grayish and hard in consistency, unlikely to be from a cardiogenic embolism originating from atrial fibrillation (Fig. 1C).
CT image of the brain 1 day after the mechanical thrombectomy, showing a hemorrhagic transformation in the insular cortex and diffuse subarachnoid hemorrhage (A). The MRA confirms the complete recanalization (B) with infarction of a large core of middle cerebral artery (MCA) territory (C, D).
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F2
A day later, his NIHSS score became 15, and CT the next day revealed a hemorrhagic transformation with an intraparenchymal hematoma in the insular cortex and diffuse subarachnoid hemorrhage (SAH) (Fig. 2A). MRI revealed complete recanalization (Fig. 2B) but also detected a large core of MCA territory infarction (Fig. 2C and 2D).
Transthoracic echocardiography image suggesting the presence of vegetation on the prosthetic atrial valve (A). The enhanced CT scan of the abdomen shows a splenic lesion that suggests either an infarct or an abscess (B). The surgically removed prosthetic aortic valve shows the formation of a huge blackish fungal vegetation (C). MRI on day 33 (D) revealed the recurrence of new cerebral infarctions (arrows).
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F3
Transthoracic echocardiography revealed the possibility of an existing vegetation on the prosthetic atrial valve (Fig. 3A). In addition, enhanced CT of the abdomen confirmed a lesion in the spleen, which suggested an infarct or abscess (Fig. 3B); thus, a splenectomy was performed on day 29. Furthermore, he underwent an aortic valve replacement on day 36, which revealed the formation of huge blackish fungal vegetation and abscess around the prosthetic valve (Fig. 3C). Although no neurological deterioration was observed during that time, brain MRI on day 20 and day 33 revealed new cerebral infarctions (Fig. 3D).
First pathological examination result indicating fibrin clots containing masses of round cells showing a morphology similar to that of atypical lymphocytes in hematoxylin-eosin staining, which suggests a tumor embolization due to malignant lymphoma (A, B). The additional investigation revealed that almost all the cells considered initially as atypical lymphocytes were in fact yeast-like fungi consisting of chain-like mycelial cells in Grocott staining (C).
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F4
This microscopic finding was consistent with E. dermatitidis infection (Fig. 4).