Case Report Thoracic spinal cord intramedullary aspergillus invasion and abscess Addason F. McCaslin, Rishi R. Lall ⇑ , Albert P. Wong, Rohan R. Lall, Patrick A. Sugrue, Tyler R. Koski Northwestern University Feinberg School of Medicine, Department of Neurological Surgery, NMH/Arkes Family Pavilion Suite 2210, 676 N Saint Clair Street, Chicago, IL 60611, USA article info Article history: Received 21 February 2014 Accepted 21 April 2014 Available online xxxx Keywords: Abscess Central nervous system vasculitis Fungi Intramedullary aspergilloma Neuroaspergillosis Precursor cell lymphoblastic leukemia- lymphoma abstract Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most com- monly in immunocompromised individuals. There have been multiple previous reports of aspergillus ver- tebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lym- phoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12–L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases. Ó 2014 Published by Elsevier Ltd. 1. Introduction Invasive central nervous system (CNS) aspergillosis is a rare form of fungal infection that may arise in immunocompromised patients [1–3]. Intracranial disease occurs most commonly and is rapidly fatal without treatment [1]. Spinal aspergillosis is more indolent, but far rarer and typically develops from contiguous vertebral osteomyelitis or systemic infection [3]. Reports in the lit- erature have catalogued multiple patients with epidural or intra- dural extramedullary abscesses, but never with intramedullary involvement [2,3]. Here we describe to our knowledge the first reported case of an intramedullary spinal cord aspergillus abscess resulting from contiguous spread of infection, and highlight the need for prompt identification and treatment to prevent the rapidly fatal sequelae of intracranial extension. 2. Case report A 19-year-old woman with a history of active acute lympho- blastic leukemia presented to an outside hospital with several weeks of progressive bilateral lower extremity weakness and fevers. MRI of the lumbar spine showed vertebral discitis and oste- omyelitis from T12–L1 with a small epidural fluid collection. Targeted bone biopsy and abscess cultures showed weak growth of aspergillus believed to be contamination. She was discharged on ceftriaxone but returned to an outside hospital several weeks later with fever, hypotension, and increased leg weakness. Lumbar puncture showed red blood cells 20 cells/lL (normal: 0 cells/lL), white blood cells 1459 cells/lL (normal: <5 cells/lL), protein 367 mg/dL (normal: 15–45 mg/dL), and glucose 19 mg/dL (normal: 50–80 mg/dL) with one culture growing aspergillus. She was rap- idly transferred to Northwestern Memorial Hospital and was found on MRI to have a rim-enhancing, expansile intramedullary lesion within the distal spinal cord at T12–L1, most consistent with abscess (Fig. 1). Serum aspergillus galactomannan enzyme immu- noassay index was 3.64 (normal: <0.5) and b-D-glucan was over 500 pg/mL (normal: <60 pg/mL), both consistent with invasive aspergillosis. She was started on intravenous voriconazole with two loading doses of 6 mg/kg followed by maintenance at 4 mg/ kg twice daily in accordance with the recommendations of the Infectious Disease Society of America [4]. She was then taken to the operating room for T11–L1 laminectomy and ultrasound- guided aspiration of her intramedullary and extramedullary abscesses. Intraoperative specimen showed abundant hyphae (Fig. 2A) and cultures grew a non-fumigatus species of aspergillus. Postoperative MRI showed resolution of the intramedullary lesion (Fig. 2B). However, her postoperative course was complicated by intracranial extension of her spinal aspergillosis resulting in rapid progression of ventriculitis and cerebral vasculitis with diffuse http://dx.doi.org/10.1016/j.jocn.2014.04.030 0967-5868/Ó 2014 Published by Elsevier Ltd. ⇑ Corresponding author. Tel.: +1 312 695 6200; fax: +1 312 695 0225. E-mail address: rishi.lall@northwestern.edu (R.R. Lall). Journal of Clinical Neuroscience xxx (2014) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: McCaslin AF et al. Thoracic spinal cord intramedullary aspergillus invasion and abscess. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.030