Successful Treatment of Cerebral Aspergillosis in a Child with Acute Lymphoblastic Leukemia

Lee, Jin; Cho, Bin; Lee, Hyun Jung; Kim, Soh Yeon; Chung, Nak Gyun; Kim, Hack Ki

Abstract

Intracranial aspergillosis is a rare pathologic condition, difficult to treat and often fatal, which generally affects immuosuppressed patients. A case of brain abscess secondary to pulmonary localization in a child with acute lymphoblastic leukemia with a favorable outcome is described. A 4-year-old boy diagnosed with acute lymphoblastic leukemia was induced with vincristine, cyclophosphamide, daunorubicin, L-asparaginase and dexamethasone. On the second week of induction chemotherapy, he suffered febrile neutropenia (absolute neutrophil count below 100). Blood and sputum culture disclosed the presence of Aspergillus fumigatus, and chest X-ray examination showed thin-walled cavitation of infiltrates compatible with aspergilloma. The patient was treated with amphotericin B (1 mg/kg/day) and with G-CSF for neutropenia. Fever subsided a few days later and complete hematologic remission was attained on the sixth hospital week, during which antifungal treatment with amphotericin B was continued. Repeated blood and sputum cultures were sterile. On the fifty-sixth hospital day, the patient suffered from afebrile tonic seizure with right side weakness. CT scan of the brain showed multiple well-circumscribed, rim-enhancing round lesions in right frontal lobe and bilateral parieto-occipital area causing gross edema and displacement of the central structures. Itraconazole was added from eightieth hospital day and supportive care was provided for brain edema. After 2 weeks, there was marked clinical improvement, and the pulmonary aspergilloma had completely regressed on follow-up chest X-ray at the sixty-fifth hospital day. Follow-up brain CT scan at the sixty-eighth hospital day showed marked decrease in size, thickness of abscess wall, and brain edema. Patient also attained neurologic improvement. Amphotericin B therapy was continued for 9 weeks (cumulative dose 908 mg, 58 mg/kg) without discer-nable side effects and the patient was discharged on the ninety-sixth hospital day with improved condition. 6 months after detection of brain abscess, magnetic resonance image of the brain showed resolution of all brain lesions. To the best of our knowledge, this is the first reported case survived CNS aspergillosis in an immunocompromised setting in Korea which was successfully treated with medical therapy only. We present a case report with a brief review.