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Cryptococcus meningoencephalitis in AIDS: parenchymal and meningeal forms
J Berkefeld1, W Enzensberger, H Lanfermann
1Institut für Neuroradiologie, Klinikum der Johann-Wolfgang-Goethe Universität, Frankfurt am Main, Germany. Berkefeld@em.uni-frankfurt.de
Abstract:
CT and MRI in one case of Cryptococcus neoformans infection showed contrast-enhancing parenchymal lesions resembling granulomata or abscesses. After an initial phase without contrast enhancement, the full extent of the lesions was visible within 2 weeks of presentation. The enhancing masses were assumed to represent intracerebral cryptococcomas. Despite evidence of massive meningeal infection on cerebrospinal fluid (CSF) examination, no radiological signs of meningitis, invasion of the Virchow-Robin spaces or ventriculitis could be demonstrated. With antimycotic treatment the contrast enhancement disappeared and cystic, partly calcified lesions remained. Recurrence of meningeal infection without radiological correlates was apparent in this stage. In a second case of proven cryptococcus meningitis, dilation of Virchow-Robin spaces or cysts in the adjacent parenchyma were the main abnormalities on MRI. Enhancing masses were not detected. These cases may represent two different reactions of the immunocompromised hosts to infection with C. neoformans: widening of the perivascular spaces as a correlate of the more typical meningeal infection and enhancing parenchymal lesions as a sign of further invasion from the CSF spaces. Enhancement of cryptococcomas, indicating an inflammatory response in the surrounding brain, is not typical in patients with impairment of immune function.
Insights
Cryptococcus neoformans infections in immunocompromised patients can present as enhancing brain lesions or widened perivascular spaces. Imaging findings depend on the host
Area of Science:
- Neuroimaging
- Infectious Diseases
- Immunocompromised Hosts
Background:
- Cryptococcus neoformans is an opportunistic pathogen causing significant morbidity and mortality in immunocompromised individuals.
- Cerebral cryptococcosis can manifest with diverse imaging findings, posing diagnostic challenges.
Observation:
- Two cases of Cryptococcus neoformans infection in immunocompromised patients revealed distinct neuroimaging features on CT and MRI.
- Case 1: Contrast-enhancing parenchymal lesions resembling cryptococcomas were observed, despite extensive meningeal infection shown in CSF, with no radiological signs of meningitis.
- Case 2: Dilation of Virchow-Robin spaces and parenchymal cysts were the primary findings in a patient with proven cryptococcal meningitis, without enhancing masses.
Findings:
- The study suggests two potential radiological patterns of C. neoformans infection in immunocompromised hosts: enhancing parenchymal lesions (cryptococcomas) and widened perivascular spaces.
- Enhancing cryptococcomas may indicate a more invasive form of the infection with an inflammatory response in the brain parenchyma.
- Widened Virchow-Robin spaces or cysts are associated with more typical meningeal infection, highlighting varied host immune responses.
Implications:
- These findings underscore the importance of correlating neuroimaging findings with clinical and CSF analysis in diagnosing and managing cryptococcal CNS infections.
- Understanding these distinct radiological patterns can aid in predicting disease progression and guiding treatment strategies in immunocompromised patients.
- The study highlights that enhancement of cryptococcomas, usually indicative of inflammation, is atypical in immunocompromised patients, suggesting altered inflammatory responses.