PDF(Pubmed)
Abstract：
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 (Veilonella, Pseudomonas). 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.
摘要：
中枢神经系统（CNS）病变，特别是侵袭性真菌病（IFDs），在免疫功能低下的患者中，诊断和治疗面临巨大挑战。我们报告了一名48岁的急性骨髓性白血病和可能的肺曲霉病的病例，他出现了左上肢的减肥症，在达到白血病缓解和伏立康唑治疗后。磁共振成像（MRI）显示右半球有出血成分的水肿性中枢神经系统病变伴有轻脑脑膜炎。抗生素和两性霉素B治疗2周后，脑活检显示慢性炎症伴脓肿和坏死，虽然文化是阴性的。临床恢复，他使用伊沙武康唑出院，同种异体移植被推迟，介绍阿扎胞苷作为维持治疗。经过初步改进,MRI恶化；重复进行脑活检，显示相似的组织学；16S宏基因组学测序分析为阳性(Veilonella，假单胞菌）。尽管美罗培南一个月，MRI没有改善。计算机断层扫描和PET扫描排除了颅外感染-炎症部位，和自身免疫发生(结节病，组织细胞增生症,中枢神经系统血管炎）由于组织学发现和单侧病变而被认为不太可能。我们假设可能的IFD伴有周围病变炎症，并成功引入了甲基强的松龙。类固醇正在逐渐减少，伊沙武康唑计划停药，并进行密切随访。总之,免疫功能低下患者中枢神经系统并发症的治疗需要跨学科的方法.
