Cladosporium cladosporioides brain abscess: an enigmatic case

A fifteen-year-old boy was brought to emergency department with complaints of altered sensorium, aphasia and right sided hemiparesis following severe dengue one month back. On physical examination, tone was flaccid and power was diminished in right upper and lower limbs. Reflexes were diminished in all four limbs. Magnetic resonance imaging showed multiple well defined thin walled ring-enhancing lesions in left basal ganglia, bilateral cerebellum, left occipital lobe and bilateral fronto-temporo-parietal lobes. The basal ganglia focus was tapped. Potassium hydroxide-calcofluor white mount of the intra-operative pus sample showed fragmented septate hyphae with folding and with wide variations in breadth. A provisional report of septate and aseptate hyphae suggestive of mixed infection was given. Empirical voriconazole was stopped and the patient was started on liposomal amphotericin B to cover a broader spectrum of molds. Subsequently, fungal culture of the pus sample grew off-white glabrous colonies in multiple culture tubes. On lactophenol cotton blue mount, shield cells were seen suggestive of Cladosporium spp. Amphotericin B was stopped after provisional identification of Cladosporium spp. was given by the laboratory and IV voriconazole was started. The identification was confirmed to be Cladosporium cladosporioides by microculture and sequencing of the internal transcribed spacer region of the 18s ribosomal DNA. The patient improved with drainage of the largest basal ganglia focus and voriconazole. This case exemplifies the potential of saprobic fungi to cause invasive infections in human.