Case Presentation:
A 37‐year‐old nondiabetic Hispanic male with past medical history of seizure disorder and intravenous drug abuse (IVDA) was brought to the hospital with altered mental status. For the past 2 days, he had fluctuating somnolence, auditory hallucination, and unsteady gait. On examination, the patient was afebrile, aphasic, and drowsy and had needle track marks on the extremities. He was found to have left‐sided weakness that progressed to left‐sided hemiplegia over 48 hours. Laboratory investigation showed leukocytosis with left shift. Computed tomography (CT) scan of the head revealed right basal ganglia mass. Magnetic resonance imaging (MRI) of the brain was promptly done that showed a non‐ring enhancing opacity in the right basal ganglia. The working diagnosis was brain abscess in the cerebritis stage. Patient received appropriate broad‐spectrum antibiotics for presumptive brain abscess. However, multiple sets of blood cultures, HIV antibody test, cryptococcal antigen, and toxoplasma antibody titers were all negative. In the next week, the leukocyte count decreased but did not normalize. A follow‐up MRI of the brain done after 1 week showed an enlarging ring‐enhancing lesion in the right basal ganglia. Emergent neurosurgical drainage was done, and 30 mL of pus was drained, microscopy of which showed fungal hyphae consistent with mucor species. Antibiotics were discontinued, and the patient was started on intravenous amphotericin B. CT scan of the sinuses and a thorough Ear, Nose, and throat (ENT) evaluation ruled out rhinosinusitis. When after 1 month of treatment with intravenous amphotericin B, the patient did not improve clinically, treatment was switched to intrathecal amphotericin B to be delivered via an Ommaya reservoir. In the next 3 months, the patient improved significantly, regaining his speech and left‐sided partial strength.
Discussion:
This case demonstrates the possibility of mucor brain abscess, although extremely rare, in immunocompetent hosts. Of approximately 30 cases of isolated CNS mucormycosis described in Ihe literature, Two thirds were seen in patients with IVDA, who presumably had injected material contaminated with zygomycete spores directly into their bloodstream. The lesions in majority of these cases were in the basal ganglia.
Conclusions:
Mucormycotic brain abscess is a dreaded disease. Its treatment should include surgical drainage and intravenous and intraventricular amphotericin B. Considering The mortality rate of this fungal infection, which is close to 50%, an index of high clinical suspicion, prompt diagnosis, and long‐term treatment is imperative to ensure survival.
Author Disclosure:
P. Kaushik, none; C. Fermin, none; S. Ghimire, none; A. Grigoriu, none.