Fusarium species intramedullary spinal cord fungus ball: case report

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The Fusarium species are one of the most common opportunistic fungal infections occurring in immunocompromised patients and are associated with high morbidity and mortality. Common sites of infection include blood, skin, nasal passages, lungs, bone, and other visceral organs. There is a paucity of literature on Fusarium infections in the brain, and the true nature and extent of central nervous system involvement is not well described. To the authors’ knowledge, there have been no reported cases of Fusarium infection of the spine. The authors report the case of a man with acute myeloblastic leukemia and resultant pancytopenia who presented with fungal sinusitis, upper- and lower-extremity weakness, and cardiopulmonary arrest. Imaging studies revealed a spinal cervical intramedullary ring-enhancing lesion. Because of the progressive nature of his symptoms, neurosurgical intervention involving a C2–3 laminectomy and drainage of the lesion was performed. Intraoperative cultures and histopathology results were positive for Fusarium species and, along with intraoperative findings, were consistent with a fungus ball. The patient was placed on a regimen of intravenous and intrathecal antifungal therapy. Unfortunately, his clinical condition declined postoperatively, and he ultimately died of disseminated infection.

ABBREVIATIONS AML = acute myeloblastic leukemia; SIMA = spinal intramedullary abscess.

Article Information

Correspondence Andrew J. Fabiano: Roswell Park Comprehensive Cancer Center, Buffalo, NY. andrew.fabiano@roswellpark.org.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.SPINE181286.

Disclosures Dr. Fabiano receives research support from Arbor Phamaceuticals.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial noncontrast CT scan of the face and orbit. Superficial soft-tissue thickening is noted in the right preorbital soft tissues. There is mucosal thickening in the right maxillary sinus and the right ethmoid air cells with extension into the right orbital cavity. There is a small focal area of abnormal attenuation likely representing phlegmon formation (white arrow), measuring 14 mm noted medially in the right orbit and exerting mass effect on the right eye globe, which is slightly deviated to the right side.

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    Initial MR images of the cervical spine. A–C: Midsagittal T2-weighted (A), T1-weighted without gadolinium (B), and T1-weighted with gadolinium (C) images. D and E: Axial sequences through the center of the lesion: T1-weighted without contrast (D) and T1-weighted with contrast (E). A ring-enhancing intramedullary spinal cord lesion is seen at C2 (cervical vertebra) measuring 15 × 9.5 mm (C and E). There is severe spinal cord edema extending from the cervicomedullary junction rostrally to the medulla and caudally to C7, causing expansion of the spinal cord from C2 to C7 (A). No other areas of enhancement are noted. On the T2-weighted image (A), there is no appreciable cyst noted, and the lesion appears hypointense.

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    Postoperative MR images of the cervical spine. A–C: Midsagittal T2-weighted (A), T1-weighted without gadolinium contrast (B), and T1-weighted with gadolinium contrast (C). D and E: Axial T1-weighted without contrast (D) and T1-weighted with contrast (E) sequences through the center of the lesion. Posterior cervical postoperative changes with persistent ring enhancement are seen (C and E). The T2 signal within the lesion is now hyperintense compared with hypointense preoperatively. This demonstrates a replacement of the gray, flecky material identified at surgery with fluid. There is very subtle interval extension of the rostral component of spinal cord edema (A).

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    Histopathological slides of cultures obtained intraoperatively from the lesion. A: The red arrows indicate fungal organisms. H & E, original magnification ×400. B: Uniform intra- and extravascular septate hyphae, with acute angle branching and variably sized conidia. Gomori methenamine silver stain, original magnification ×400. Figure is available in color online only.

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