Lesão expansiva cerebral devida a citomegalovírus: relato de caso e revisão da literatura

Cytomegalovirus (CMV) disease in acquired immunodeficiency syndrome (AIDS) patients most commonly presents as chorioretinitis and gastro-intestinal infection. Neurological involvement due to CMV may cause several clinical presentations: polyradiculitis, myelitis, encephalitis, ventriculo-encephalitis, and mononeuritis multiplex. Rarely, cerebral mass lesion is described. We report a 39 year-old woman with AIDS and previous cerebral toxoplasmosis. She presented with fever, seizures, and vulval ulcers. Her chest X-ray showed multiple lung nodules, and a large frontal lobe lesion was seen in a brain computed tomography scan. She underwent a brain biopsy through a frontal craniotomy, but her condition deteriorated and she died in the first postoperative day. Histopathological studies and immunohistochemistry disclosed CMV disease, and there was no evidence of cerebral toxoplasmosis, bacterial, mycobacterial or fungal infection. CMV disease should be considered in the differential diagnosis of cerebral mass lesion in AIDS patients. High suspicion index, timely diagnostic procedures (surgical or minimally invasive), and proper utilization of prophylactic and therapeutic medication could improve outcome of these patients.As doenças causadas pelo citomegalovírus (CMV) em pacientes com a síndrome da imunodeficiência adquirida apresentam-se principalmente como corioretinite ou comprometimento gastrointestinal. No sistema nervoso central, o CMV pode causar diversas síndromes clínicas: poliradiculite, mielite, encefalite, ventrículo-encefalite e mononeurite múltipla. Raramente, lesões expansivas cerebrais são descritas. Os autores relatam o caso de uma paciente de 39 anos com antecedentes de infecção pelo HIV e toxoplasmose cerebral, que apresentou-se com febre, convulsões e úlceras vulvares. O raios-X de tórax demonstrou múltiplos nódulos pulmonares e a tomografia computadorizada de crânio evidenciou extensa lesão no lobo frontal esquerdo. Após ser submetida à craniotomia, evoluiu com piora clínica, falecendo no primeiro dia de pós-operatório. Os estudos histopatológicos e imunohistoquímicos demonstraram doença citomegálica. Foram excluídas toxoplasmose cerebral e infecção bacteriana, micobacteriana ou fúngica. Concluímos que, embora seja extremamente raro, o CMV deve ser considerado no diagnóstico diferencial das lesões expansivas cerebrais em pacientes com infecção pelo HIV. Um elevado índice de suspeita, procedimentos diagnósticos oportunos (cirúrgicos ou minimamente invasivos), e o adequado uso de antivirais (terapêuticos e profiláticos) podem melhorar o prognóstico desta letal manifestação

Abscesso tuberculoso cerebral em paciente com AIDS: relato de caso e revisão da literatura

Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment are the mainstay in the management of these uncommon lesions.Os abscessos tuberculosos cerebrais em pacientes com aids são raros, existindo apenas 8 casos publicados. Os autores relatam o caso de uma paciente de 34 anos com aids e antecedente de toxoplasmose cerebral, que foi admitida por cefaléia e convulsões. A tomografia computadorizada de crânio evidenciou lesão frontal única, grande, com realce anular e efeito expansivo. Diante da suspeita de abscesso cerebral foi submetida a trepanação, drenando material purulento e demonstrando presença de abundantes bacilos ácido-álcool resistentes. Abordagem cirúrgica e clínica oportuna determinaram uma boa evolução. Os abscessos tuberculosos devem ser considerados no diagnóstico diferencial das massas intracranianas em pacientes com aids. Excisão cirúrgica ou aspiração por estereotaxia e tuberculostáticos constituem as bases do tratamento destas lesões incomuns

Aspergilosis cerebral causada por Aspergillus fumigatus en paciente con SIDA: primer reporte de caso demostrado por cultivo en Brasil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA

Cerebral mass lesion due to cytomegalovirus in a patient with AIDS: case report and literature review Lesão expansiva cerebral devida a citomegalovírus: relato de caso e revisão da literatura

Cytomegalovirus (CMV) disease in acquired immunodeficiency syndrome (AIDS) patients most commonly presents as chorioretinitis and gastro-intestinal infection. Neurological involvement due to CMV may cause several clinical presentations: polyradiculitis, myelitis, encephalitis, ventriculo-encephalitis, and mononeuritis multiplex. Rarely, cerebral mass lesion is described. We report a 39 year-old woman with AIDS and previous cerebral toxoplasmosis. She presented with fever, seizures, and vulval ulcers. Her chest X-ray showed multiple lung nodules, and a large frontal lobe lesion was seen in a brain computed tomography scan. She underwent a brain biopsy through a frontal craniotomy, but her condition deteriorated and she died in the first postoperative day. Histopathological studies and immunohistochemistry disclosed CMV disease, and there was no evidence of cerebral toxoplasmosis, bacterial, mycobacterial or fungal infection. CMV disease should be considered in the differential diagnosis of cerebral mass lesion in AIDS patients. High suspicion index, timely diagnostic procedures (surgical or minimally invasive), and proper utilization of prophylactic and therapeutic medication could improve outcome of these patients.<br>As doenças causadas pelo citomegalovírus (CMV) em pacientes com a síndrome da imunodeficiência adquirida apresentam-se principalmente como corioretinite ou comprometimento gastrointestinal. No sistema nervoso central, o CMV pode causar diversas síndromes clínicas: poliradiculite, mielite, encefalite, ventrículo-encefalite e mononeurite múltipla. Raramente, lesões expansivas cerebrais são descritas. Os autores relatam o caso de uma paciente de 39 anos com antecedentes de infecção pelo HIV e toxoplasmose cerebral, que apresentou-se com febre, convulsões e úlceras vulvares. O raios-X de tórax demonstrou múltiplos nódulos pulmonares e a tomografia computadorizada de crânio evidenciou extensa lesão no lobo frontal esquerdo. Após ser submetida à craniotomia, evoluiu com piora clínica, falecendo no primeiro dia de pós-operatório. Os estudos histopatológicos e imunohistoquímicos demonstraram doença citomegálica. Foram excluídas toxoplasmose cerebral e infecção bacteriana, micobacteriana ou fúngica. Concluímos que, embora seja extremamente raro, o CMV deve ser considerado no diagnóstico diferencial das lesões expansivas cerebrais em pacientes com infecção pelo HIV. Um elevado índice de suspeita, procedimentos diagnósticos oportunos (cirúrgicos ou minimamente invasivos), e o adequado uso de antivirais (terapêuticos e profiláticos) podem melhorar o prognóstico desta letal manifestação

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil Aspergilosis cerebral causada por Aspergillus fumigatus en paciente con SIDA: primer reporte de caso demostrado por cultivo en Brasil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.<br>La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA