CASE REPORTS Cerebellar Aspergillosis: Case Report and Literature Review Ersin Erdogan, M.D., Murat Beyzadeoglu, M.D., Fikret Arpaci, M.D., Bülent Celasun, M.D. Departments of Neurosurgery (EE), Radiation Oncology (MB), Medical Oncology (FA), and Pathology (BC), Gulhane Military Medical School, Ankara, Turkey OBJECTIVE AND IMPORTANCE: An unusual, but not unique, case of cere- bellar aspergillosis associated with autologous peripheral blood stem cell transplantation for breast cancer is presented. CLINICAL PRESENTATION: A 45-year-old woman with breast cancer un- derwent chemotherapy and radiotherapy as well as autologous periph- eral blood stem cell transplantation. She developed a cerebellar as- pergillosis abscess that was treated successfully with two surgical resections. INTERVENTION: After removal of pus and the abscess wall, the patient received local application of amphotericin B (AmB). She received AmB 1 mg/kg/d for 3 months and itraconazole 100 mg/kg/d for 1 year. After 3 months of AmB treatment, magnetic resonance imaging revealed that disease had not recurred. CONCLUSION: In cases of central nervous system aspergillosis, to increase the therapeutic efficiency, AmB can also be applied to the abscess cavity. Computed tomographic and contrast-enhanced magnetic resonance im- aging scans play an important role in establishing early diagnosis in high-risk, immunocompromised patients. (Neurosurgery 50:874–877, 2002) Key words: Aspergillosis, Breast, Cancer, Cerebellar, Treatment C entral nervous system (CNS) infec- tions are major complications in cancer treatment, mainly because of the use of immunosuppressive therapy in- cluding corticosteroids, chemotherapy, and total body irradiation. Infection- related morbidity and mortality repre- sent a significant barrier to both imme- diate and long-term survival after bone marrow transplantation (13). CNS infec- tions occur in 3 to 8% of patients after bone marrow transplantation (13). Cyto- megalovirus encephalitis, cerebral as- pergillosis, and cerebral toxoplasmosis are the most common CNS infections (13). Aspergillosis remains one of the most difficult infections to treat, espe- cially in immunocompromised pa- tients. In these patients, the common pathway for the fungus to reach the CNS is hematogenous dissemination from extracranial foci, usually the lungs (5). Mortality rates range from 75 to 100% despite intensive treatment with amphotericin B (AmB) in many cases (8, 19). Cerebral aspergillosis carries a mortality rate close to 100%, and diagnosis is often made after death (2, 8, 18, 19). Nosocomial trans- mission has been documented (7). In this report, we present an unusual, but not unique, case of cerebellar aspergil- losis in a woman who received an au- tologous peripheral blood stem cell transplant to treat breast cancer. CASE REPORT A 45-year-old woman with Stage IIIA (T2, N2, M0) breast cancer underwent mastectomy, chemotherapy, autologous peripheral blood stem cell transplanta- tion, and radiotherapy. Two months later, she developed ataxia and gait dis- turbance. A computed tomographic (CT) scan and magnetic resonance im- aging (MRI) scan revealed a large right cerebellar lesion, with ringlike contrast enhancement (Fig. 1). She underwent to- tal surgical removal of the cerebellar ab- scess with suboccipital craniectomy. The main surgical finding was pinkish- white pus. A pathological examination revealed the presence of Aspergillus fu- migatus. The postoperative course was uneventful. A CT scan was performed 1 month later because of ataxia; the scan again revealed an intracerebellar abscess. She underwent reoperation 5 weeks after the initial operation. The dura was opened, and similar purulent material was revealed. After removal of the pus and the abscess wall, AmB was applied locally. The patient was treated with AmB 1 mg/kg/d for 3 months and itra- conazole 100 mg/kg/d for 1 year. After 3 months of AmB treatment, MRI scans revealed no recurrence of infection (Fig. 2). The patient gradually improved, with disappearance of all symptoms within 3 months’ time. She completed her 2-year follow-up period, and she is still alive and well. Pathological findings Histopathologically, the cerebellar samples demonstrated a poorly demar- cated inflammatory infiltrate consisting mostly of polymorphonuclear cells and macrophages (Fig. 3). Giant cells and hemosiderin deposition were also present. Branching septate hyphae char- acteristic of Aspergillus were visible on hematoxin and eosin-stained slides. Grocott’s methenamine silver stain al- lowed the organisms to be visualized more clearly (Fig. 4). 874 Neurosurgery, Vol. 50, No. 4, April 2002