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| LETTER TO THE EDITOR |
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| Year : 2019 | Volume
: 2
| Issue : 3 | Page : 157-158 |
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Isolated fungal granuloma mimicking a high-grade glioma
Kriti Chauhan1, Hitesh Chaudhari2, Vineet Saggar3, Ritu Bisht1
1 Department of Pathology, Polo Labs, Ivy Hospital, Panchkula, Haryana, India
2 Department of Radiology, Ivy Hospital, Panchkula, Haryana, India
3 Department of Neurosurgery, Ivy Hospital, Mohali, Haryana, India
| Date of Submission | 01-Aug-2019 |
| Date of Decision | 22-Aug-2019 |
| Date of Acceptance | 30-Aug-2019 |
| Date of Web Publication | 26-Sep-2019 |
Correspondence Address:
Dr. Kriti Chauhan
#525, GH2, Shikhar Apartments, MDC, Sec-5, Panchkula - 134 114, Haryana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/glioma.glioma_17_19
How to cite this article:
Chauhan K, Chaudhari H, Saggar V, Bisht R. Isolated fungal granuloma mimicking a high-grade glioma. Glioma 2019;2:157-8 |
Dear Editor,
Aspergillus is the most common causative fungal pathogen, accounting for 56%–69% of intracranial fungal infections.[1] It enters the central nervous system via a hematogenous route from a systemic focus like the lungs, by contiguous spread from paranasal sinuses or the ear, or by direct inoculation following surgery or trauma.[2] Temperate and humid climates, like that of India, favor the growth of this fungus, especially during agricultural activities such as plowing, which causes the dispersion of spores into the environment.[1],[2] On inhalation, the fungus resides in the respiratory tract. Any kind of temporary immunosuppression or local alteration of immunity promotes the mucosal invasion of the fungus. The immune system tries to prevent its spread by inducing a granulomatous response, which forms organized nodules called granulomas, resulting in a mass-forming lesion.[3] We report a case of a 34-year-old male presenting with complaints of generalized acute headaches, diminishing right eye vision, and weakness. His brain magnetic resonance imaging (MRI) showed an ill-defined heterogeneous lesion in the right temporoparietal lobe with marked surrounding edema and mass effect, suggestive of an infiltrative glioma [Figure 1]. The patient was nonreactive for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C virus. The mass was excised and sent for histopathological examination. Examined sections showed multiple noncaseating type of epithelioid cell granulomas with giant cells, lymphoplasmacytic cells, and collection of neutrophils [Figure 2]. The surrounding cerebral parenchyma showed reactive gliosis and vascular proliferation. No evidence of any malignancy or metastasis was seen. On further careful examination, septate and regular right angle-branching fungal hyphae of Aspergillus were seen in the giant cells and amidst neutrophilic abscesses [Figure 3]. A periodic acid–Schiff stain highlighted the fungal profiles. No evidence of any extracranial disease (sinonasal or pulmonary) was found upon radiological and clinical examination. Thus, a diagnosis of isolated Aspergillus granuloma was given. The patient was started on an intravenous infusion of liposomal amphotericin B at 5 mg/kg slowly for 14 days, followed by oral administration of voriconazole. After 1 month, his condition had markedly improved. His brain MRI showed a significant decrease in lesion size. It has been reported that, apart from granulomatous inflammation, angioinvasiveness is a very important factor in determining disease outcome.[4] Its absence reflects the competence of the immune system and a favorable response to therapy. In fact, a granulomatous response and a lack of angioinvasion are the best markers of a competent immune system, or vice versa; this is why there was no extracranial disease focus in our patient. A likely pathway of the central nervous system spread is via the permeative destruction of bone in the sinus walls, with the help of fungal enzymes such as elastase.[5] The most common differential diagnoses in such cases are tuberculosis and gliomas, which can be ruled out by histology with the assistance of ancillary tests such as Ziehl–Neelsen stain and immunohistochemistry. To conclude, immune competence does not rule out the possibility of a fungal infection in the brain. A differential diagnosis of fungal granuloma should always be considered, especially in young patients like ours who come from agricultural regions of India. | Figure 1: Brain magnetic resonance imaging of an ill-defined heterogeneous mass lesion in the right temporoparietal lobes with marked surrounding edema (arrow) and a mild midline shift to the left
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 | Figure 2: Scanner view showing scattered numerous epithelioid cell granulomas with giant cells (arrows) (hematoxylin-eosin staining, original magnification 40×)
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 | Figure 3: High-power view showing septate fungal hyphae in giant cells (A; arrow) and in neutrophil abscesses (B; arrows) (hematoxylin-eosin staining, original magnification 400×). Fungal hyphae in giant cells (C; arrows) and neutrophil abscesses (D; arrow) (Periodic acid–Schiffs staining, original magnification 400×)
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Acknowledgment
We are thankful to the technical staff for their help in carrying out this study, the head of department of pathology for her guidance, and the chairman of hospital for his immense support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained the patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understood that his name and initial would not be published and due efforts would be made to conceal their identity.
| References | |  |
| 1. | Sundaram C, Murthy JM. Intracranial Aspergillus granuloma. Patholog Res Int 2011;2011:157320.  |
| 2. | Shankar SK, Mahadevan A, Sundaram C, Sarkar C, Chacko G, Lanjewar DN, et al. Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario. Neurol India 2007;55:198-215. [ PUBMED] [Full text] |
| 3. | Challa S, Uppin SG, Purohit AK. Isolated cerebral Aspergillus granuloma with no obvious source of infection. Neurol India 2007;55:289-91. [ PUBMED] [Full text] |
| 4. | Nadkarni TD, Desai KI, Muzumdar D, Goel A, Shenoy A. Ischaemic complications after surgical resection of intracranial aspergilloma. J Clin Neurosci 2003;10:500-2. |
| 5. | Kumar D, Nepal P, Singh S, Ramanathan S, Khanna M, Sheoran R, et al. CNS aspergilloma mimicking tumors: Review of CNS Aspergillus infection imaging characteristics in the immunocompetent population. J Neuroradiol 2018;45:169-76. |
[Figure 1], [Figure 2], [Figure 3]
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