Cerebral phaeohyphomycosis presenting as an intraventricular mass.

Cerebral phaeohyphomycosis presenting as an intraventricular mass Sir, Phaeohyphomycoses are subcutaneous and systemic infections caused by dematiaceous fungi with dark walled hyphae due to the presence of melanin in the cell wall.Cerebral phaeohyphomycosis presents most commonly as a cerebral abscess and Cladophialophora bantiana accounts for the majority of the reported cases thus far. A 20-year-old woman presented with headache, vomiting and progressive weakness of right upper and lower limbs for three months. Physical examination revealed bilateral papilloedema, right sided hemiparesis and spastic gait. Magnetic resonance imaging (MRI) of the brain showed an enhancing lesion in the left lateral ventricle causing dilatation of the ipsilateral lateral ventricle. The choroid plexus of the ipsilateral ventricle was thickened [Figure 1]. She underwent a left frontal craniotomy and subtotal excision of the mass. At surgery the mass was intraventricular and was attached to the choroid plexus and had papillary projections. Anteriorly the mass was adherent to the caudate nucleus and the thalamostriate vein. The histopathological examination showed a circumscribed nodule in the choroid plexus consisting of several discrete necrotising granulomata composed of multinucleated giant cells, histiocytes and lymphocytes. Pigmented branching hyphae were seen within the necrotic centers of the granulomata and within some of the giant cells [Figure 2]. The biopsy was reported as necrotising granulomatous Figure 1: Magnetic resonance imaging (MRI) of the brain, T1W post gadolinium image showing an enhancing lesion in the left lateral ventricle causing dilatation of ipsilateral lateral ventricle. Figure 2: Photomicrograph showing the hyphae within the giant cells of the granuloma (H/E, 90x) inflammation consistent with phaeohyphomycosis. Species identification was not possible, as cultures had not been submitted. She was advised systemic antifungal treatment with amphotericin B, but was discharged at request on oral ketoconazole. Two weeks later she presented with symptoms of raised intracranial pressure. A computed tomogram of the brain showed an increase in the dilatation of the left lateral ventricle. She underwent an emergency left ventriculoperitoneal shunt. CSF fungal and mycobacterial cultures done at this point were negative. She was started on intravenous Amphotericin B and a cumulative dose of 1.5 gms was given. She was discharged on a six-month course of oral itraconazole. Cerebral phaeohyphomycosis was first reported in 1952 by Binford and since then several cases have been reported. Apart from Cladophialophora bantiana other agents responsible are Cladophialophora bantiana is neurotropic in nature and may cause brain abscess in both normal and immunosuppressed …