(Kiosk 3) Intracranial Phaeohyphomycosis in an Immunocompetent Individual: A Case Report

Case Diagnosis: Intracranial Phaeohyphomycosis in an Immunocompetent Individual.

Case Description or Program Description: A 79-year-old female presented as a code stroke after being found down with presumed loss of consciousness. The patient later endorsed mild right-sided numbness weakness 1 day prior. Examination was notable for decreased sensation in the V2 and V3 distributions of the face, 4-4+/5 strength and decreased sensation in the right extremities and decreased fine motor movements in the right hand. An initial CT head showed mild left thalamic edema. Follow up MRI Brain demonstrated a 1.9 x 1.3 x 1.9 cm enhancing mass within the left thalamic region.

Setting: Acute care hospital with transition to skilled nursing facility mid-treatment.

Assessment/Results: Given the presentation and radiologic findings, highest on the differential was neoplasm. Mass biopsy showed pigmented hyphae without neoplastic features. The patient was started on empiric antifungal with Amphotericin B and Voriconazole. Cultures grew Cladophialophora Bantiana, a specific pigmented fungus causing Phaeohyphomycosis. The patient remained on the same treatment. Upon resolution of symptoms and negative MRI, the medication regimen was reduced to Voriconazole monotherapy. The patient was ultimately discharged to a skilled nursing facility for remaining treatment and rehabilitation.

Discussion (relevance): Neuroinfection with Cladophialophora Bantiana is frequently fatal. An important predisposing factor includes immunodeficiency, although several cases have been noted in patients with an intact immune system. Prompt identification and treatment is important in prognosis and can be delayed as fungal abscesses commonly mimic more common masses or strokes. Treatment includes antifungals with or without surgical resection. In our case, the infection reacted adequately to antifungals alone with resolution per examination and imaging.

Conclusions: Clinicians who treat patients who present with mass lesions of the brain should maintain a broad differential diagnosis which includes fungal infections. These patients should have tissue sent for culture even when non-infectious etiology is favored to not delay proper diagnosis and prompt treatment.