PMC8416634_01
Chest X-ray September 25th, 2018, Moderate opacification in the inferior left hemithorax likely related to a combination of pneumonia and effusion.
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His chest radiography was consistent with left lower lobe pneumonia with small left pleural effusion (Fig. 1).
CT-Chest, October 10, 2018: Large consolidation in the left lower lobe and patchy opacities in the right lung. There is also small bilateral pleural effusion as well as enlarged mediastinal lymph nodes.
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The CT scan confirmed pneumonia with small bilateral pleural effusion and showed patchy opacities with scattered sub-centimetric pulmonary nodules and bilateral paratracheal and hilar lymph nodes (Fig. 2).
A) MRI head October 5, 2018, upon Emergency Room visit for confusion: ring-enhancing lesion at left frontal lobe measuring 3.9 x 3.1 x 2.5 cm diameters. The lesion showed a central bright T2/FLAIR signal with a rim of low T2 signal along with diffusion restriction. Postcontrast administration exhibited smooth rim enhancement associated with surrounding white matter edematous changes. The previously described lesion is in favor of a cerebral abscess causing adjacent mass effect with the involvement of medial anterior right cingulate gyrus. The lesion demonstrates a subependymal extension at the level of the left frontal horn with no signs of ventriculitis. B) MRI head November 10th, 2019, Follow-up postoperative changes of left frontal craniotomy for resection of the left frontal fungal abscess. An enhancing nodule is again noticed in the anterior interhemispheric fissure, slightly predominant on the left side, smaller measured approximately 8 x 9 x 8 mm. There is unchanged T2/FLAIR hyperintensity likely in keeping with gliosis. There is no evidence of diffusion restriction or new areas of abnormal contrast enhancement. There are few scattered foci of T2/FLAIR hyperintensity involving the periventricular and deep white matter of both cerebral hemispheres, likely reflecting mild chronic microvascular ischemic changes. The major intracranial flow voids are unremarkable. The previously described changes indicate favorable evolution of the postoperative changes of abscess resection.
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His head MRI showed a left frontal lobe abscess for which a neurosurgical procedure was carried out for surgical removal (Fig. 3).
Microscopic examination of deep culture from brain October 7th, 2018, Fungal hyphae are seen; 1 + Aspergillus fumigatus.
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Aspergillus fumigatus. (Fig. 4). After his brain surgery, the patient rapidly improved with voriconazole 450 mg given intravenously every 12 h and was discharged on voriconazole 250 mg twice daily orally with regular monitoring to ensure the drug plasma level remained in the therapeutic zone.