Cavazza Gabriele, Motto Cristina, Regna-Gladin Caroline, Travi Giovanna, Di Gennaro Elisa, Peracchi Francesco, Monti Bianca, Corti Nicolò, Greco Rosa, Minga Periana, Riva Marta, Rimoldi Sara, Vecchi Marta, Rogati Carlotta, Motta Davide, Pazzi Annamaria, Vismara Chiara, Bandiera Laura, Crippa Fulvio, Mancini Valentina, Sessa Maria, Oltolini Chiara, Cairoli Roberto, Puoti Massimo
Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy.
Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy.
Antibiotics (Basel). 2024 Apr 24;13(5):387. doi: 10.3390/antibiotics13050387.
Central nervous system (CNS) lesions, especially invasive fungal diseases (IFDs), in immunocompromised patients pose a great challenge in diagnosis and treatment. We report the case of a 48-year-old man with acute myeloid leukaemia and probable pulmonary aspergillosis, who developed hyposthenia of the left upper limb, after achieving leukaemia remission and while on voriconazole. Magnetic resonance imaging (MRI) showed oedematous CNS lesions with a haemorrhagic component in the right hemisphere with lepto-meningitis. After 2 weeks of antibiotics and amphotericin-B, brain biopsy revealed chronic inflammation with abscess and necrosis, while cultures were negative. Clinical recovery was attained, he was discharged on isavuconazole and allogeneic transplant was postponed, introducing azacitidine as a maintenance therapy. After initial improvement, MRI worsened; brain biopsy was repeated, showing similar histology; and 16S metagenomics sequencing analysis was positive (, ). Despite 1 month of meropenem, MRI did not improve. The computer tomography and PET scan excluded extra-cranial infectious-inflammatory sites, and auto-immune genesis (sarcoidosis, histiocytosis, CNS vasculitis) was deemed unlikely due to the histological findings and unilateral lesions. We hypothesised possible IFD with peri-lesion inflammation and methyl-prednisolone was successfully introduced. Steroid tapering is ongoing and isavuconazole discontinuation is planned with close follow-up. In conclusion, the management of CNS complications in immunocompromised patients needs an interdisciplinary approach.
中枢神经系统（CNS）病变，尤其是免疫功能低下患者的侵袭性真菌病（IFD），在诊断和治疗方面构成了巨大挑战。我们报告了一例48岁患有急性髓系白血病且可能患有肺曲霉病的男性病例，该患者在白血病缓解后且正在服用伏立康唑时出现了左上肢肌无力。磁共振成像（MRI）显示右半球有水肿性CNS病变，并伴有蛛网膜下腔出血性成分及软脑膜炎。在使用抗生素和两性霉素B治疗2周后，脑活检显示为慢性炎症伴脓肿和坏死，而培养结果为阴性。患者实现了临床康复，出院时服用艾沙康唑，异基因移植被推迟，并引入阿扎胞苷作为维持治疗。在最初病情改善后，MRI显示病情恶化；再次进行脑活检，显示出相似的组织学特征；16S宏基因组测序分析呈阳性（，）。尽管使用了1个月的美罗培南，MRI仍未改善。计算机断层扫描和PET扫描排除了颅外感染性炎症部位，并且由于组织学检查结果和单侧病变，自身免疫性病因（结节病、组织细胞增多症、中枢神经系统血管炎）被认为不太可能。我们推测可能是伴有病灶周围炎症的IFD，并成功引入了甲泼尼龙。目前正在逐渐减少类固醇药物的用量，并计划停用艾沙康唑，同时进行密切随访。总之，免疫功能低下患者中枢神经系统并发症的管理需要跨学科方法。
