Cladosporium bantianum (trichoides) infection of the brain.

TD Nadkarni, A Goel, A Shenoy, AP Karapurkar 
 Dept of Neurosurgery, Seth G S Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

Correspondence Address:
T D Nadkarni
Dept of Neurosurgery, Seth G S Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

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::   Introduction

Cladosporium bantianum a highly neurotropic pigmented fungus, appears as pigmented septate hyphae easily identifiable in tissue sections due to their natural golden brown colour. Cerebral lesions caused by this fungus are rare. Our literature review revealed 21 reports of cerebral abscess caused by this variety of fungus[1],[2],[3],[4],[5],[6],[7],[8]. Of these, 2 reports have been from the departments of Neurosurgery and Pathology of the presenting authors[4],[5].

::   Case report

A 32-year-old male patient, otherwise healthy, suffered an episode of generalised convulsions one month before admission to our unit. Since the convulsion, he had associated severe bitemporal headache. Computerised tomographic (CT) scan showed multiple, confluent, ring, enhancing lesions in the left parietooccipital region suggestive of 'tuberculoma' (See [Figure:1]). The surrounding white matter was oedematous. Anti-tuberculosis treatment was started. Inspite of the treatment for 2 weeks, he deteriorated. Over one week, he developed progressive right hemiparesis, aphasia and worsened in sensorium. Chest X-ray was normal. There was no measurable immune deficiency. The patient underwent a left parieto-occipital craniotomy with excision of the conglomerate of brain abscesses. About 8 ml of greenish yellow, non-foul smelling pus was drained. Histopathlogical examination of the brain abscesses revealed typical features of Cladosporium, bantianum. Unstained clear preparation showed golden brown fungal filaments of variable lengths. The haematoxylin and eosin stained slide showed necrosis, infiltration by neutrophils, lymphocytes and multinucleated giant cells. Golden brown branching septate filaments were seen in the neurotic tissue with giant cells. Gomori methanamine silver stained sections showed irregular branching septate fungal hyphae in large numbers. Cladosporium bantianurn was cultured from the neurotic debris. He was treated with liposome supplemented amphoteriscin B. However, the patient progressively worsened and died 20 days after the operation.

At autopsy, the brain was markedly oedematous and weighed 1050 grams. Greenish black granulation tissue, full of fungus was seen in the basal cisterns and along the blood vessels. Cut section showed multiloculated, irregular brain abscesses in both the cerebral hemispheres. There was evidence of leptomeningitis and ventriculitis. There were multiple small abscesses and granulomatous nodules in both the lobes of the lung as well. Microscopic examination and culture at all these sites confirmed the causative agent to be Cladosporium bantianum.

::   Discussion

Opportunist fungal infections of the brain are rare. More often such brain infections are seen in mal-nourished, debilitated and immuno-compromised individuals. However, rarely healthy individuals may also be affected as in the present case and the one reported by us earlier[5]. The fungus is usually found in the lungs, gastrointestinal tract, ear or skin and has significant affinity for nervous tissue in man and animals[2]. The mode of entry to the brain in most of the reported cases has been obscure. However, haematogenous spread to the brain is more likely[6]. The clinical syndrome resulting from cerebral infection from the Cladosporium bantianurn variety of fungus is termed 'cladosporiosis'. The infection may result in the formation of single or multiple abscesses. The characteristic microscopic features are the golden brown septate branching hyphae, 2-6 nm in diameter and of variable length. These can be easily identified in unstained slides due to their natural colour. Among the dematiaceous fungi (pigmented olivaceous brown), Cladosporium bantianurn is highly neurotropic. Treatment remains an enigma. Surgical excision and antifungal drugs have proved futile. The organism produces recurrent infection despite therapy and often kills the patient[2],[7]. Sixteen of the 21 cases reported so far, which were treated surgically, showed recurrence and died with a period of 3-11 months after surgery[5]. Fluocytosine has been shown to be effective against Cladosporium bantianum[9]. This drug was not available fortherapy.

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