Improved survival in central nervous system aspergillosis: a series of immunocompromised children with leukemia undergoing stereotactic resection of aspergillomas

Report of four cases

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✓Central nervous system (CNS) aspergillosis remains a daunting diagnosis. This opportunistic mycosis historically carries a mortality rate approaching 100% in immunocompromised patients, with death ensuing within days after the onset of neurological symptoms. From their literature review, the authors concluded that children contracting CNS aspergillosis while undergoing systemic chemotherapy for leukemias represent a particularly unfortunate prognostic group. Antifungal medications prove ineffective for treating CNS aspergillosis in patients immunocompromised because of their chemotherapy regimens. In contrast, withholding chemotherapy to reverse immunosuppression, thereby improving the efficacy of antifungal medications, allows for progression of the primary leukemic disease. The authors present a series of four immunosuppressed patients whose course of treatment for leukemia was complicated by CNS Aspergillus sp. abscesses. Multiple cerebral fungal abscesses developed in two patients and a single cerebral abscess developed in two. All four patients underwent frameless stereotactic resection of the aspergilloma. All children later experienced resolution of their CNS infections and full neurological recovery. At 2- to 4-year follow ups, one patient has died of leukemia and the other three continue to thrive without evidence of recurrent aspergillosis. Given the grave natural history cited in the literature for this disease when medical treatment is instituted alone, the authors stress the crucial role of stereotactic neurosurgery for the intelligent treatment of immunocompromised children suspected of harboring a CNS aspergilloma abscesses. The authors propose that the goal for successful treatment in these patients should be gross-total resection of the abscess, its wall, and its capsule.

Article Information

Address reprint requests to: Charles A. Middelhof, M.D., 305 Brunswick Road, Stephens City, Virginia 22655. email: neurodock@yahoo.com.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Axial head CT scan demonstrating a posterior, round hyperdense right frontal lobe.

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    Case 2. Axial T2-weighted MR images of the head demonstrating a left parietal hyperintense mass (left) and two right-sided, hyperintense temporoparietal lesions with some areas of heterogeneous intensity (right). A right extraaxial osseous cyst was incidentally seen. Given its asymptomatic nature, we did not intervene at that time.

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    Case 3. Left: Contrast-enhanced T1-weighted MR image demonstrating a more superficial left occipital lesion (arrow). Right: A T1-weighted MR image demonstrating a second, deeper hyperintense lesion (arrowhead).

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