Radiology of Scedosporium infections

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Radiology of Scedosporium infections

• Enrique Marco de Lucas
• Hospital Universitario Marqués de Valdecilla
• Santander SPAIN

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SANTANDER
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SUMMARY

• Brief overview cases S apiospermium
• Our experience with S prolificans imaging in
  immunocompromised patients
• Pulmonary
• CNS

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SCEDOSPORIUM INFECTIONSCLINICAL CONDITIONS

• Superficial infections in immunocompetent
  patients
• Colonization of respiratory system in patients
  with cystic fibrosis or AIDS
• Disseminated infections in deep immunocompromised
  patients.

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S. apiospermium

• Mycetoma developed in an old pneumoconiosis
  sequelae cavity.
• Mycological cultures demonstrated S.
  apiospermum.
• Lung scedosporiosis a differential diagnosis of
  aspergillosis

Al Refaï et al. Eur J Card Thorac Surg
20025938-9.
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S. apiospermium
Pseudallescheriasis of the Lung and Central
Nervous System. Multimodality Imaging Ba D.
Nguyen AJR 2001 176257-258
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SCEDOSPORIUM PROLIFICANS

• Haematologic malignancies
• Immunocompromised patients
• Deep and prolonged neutropenia

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OUR EXPERIENCE

• 18 patients
• 10 males and 8 females
• Age 5-66 years
• All with respiratory failure
• 7 patients with CNS complications
• Diagnosis established by
• Blood 9
• Autopsy 6
• Sputum 3

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OUR EXPERIENCE

• Initial diagnoses
• Acute myeloid leukemia 6
• Acute lymphoid leukemia 3
• Myeloma 2
• Myelodisplasia, CML, Liver transplantation
• Treatment
• Bone marrow transplantation 10
• Allogeneic .. 7
• Autollogous .. 3

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1- Pulmonary infection
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2- Disseminated infection
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PULMONARY INFECTION

• Progressive dyspnea and fever
• Imaging follow-up
• Chest radiography

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CHEST RADIOGRAPHY

• Low technical quality
• Multiple previous residual pathology
• Growing bilateral patchy condensations
• Non-specific
• Rapid evolution

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CHEST CT

• CT computed tomography
• Higher sensitivity
• Lesser availability for very sick patients
• Bilateral patchy condensation of alveolar space
• Ground-glass opacities

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A 37 y.o. male acute myeloblastic leukemia who
received an allogeneic BMT. He presented with
dyspnea and respiratory failure. Frontal chest
radiography showed multiple bilateral
condensations.
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A 37 y.o. male acute myeloblastic leukemia who
received an allogeneic BMT. He presented with
dyspnea and respiratory failure. Frontal chest
radiography showed multiple bilateral
condensations. He died 48 hours later. Autopsy
demonstrated diffuse hemorrhagic lesions in both
lungs. Microscopyc images showed fungal thrombi
and invasion of the vessels wall by Scedosporium
prolificans.
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A 34 y.o female with chronic myelogeneous
leukemia after non familial allogeneic-BMT. 24
hours high-grade fever and dyspnea. Chest
radiography showed diffuse parenchymal
opacification in right upper lobe. 48 hours
later chest X-ray-follow up demonstrated evident
deterioration with multiple patchy bilateral
condensations and diffuse opacification of the
lower left lobe.
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• CT scans demonstrated bilateral patchy peripheric
  condensations.
• Colonies of a fungus, later identified as S.
  prolificans were cultured from sputum.
• She died 24 hours later.

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1 day
A 45-y-o patient with multiple myeloma.
Allogeneic BMT 56 day Fever. Chest radiography
right lower lobe condensation. Blood
Scedosporium prolificans. Necropsy bilateral
pulmonary condensation. Infection heart, and
hyphae infarcts at basal ganglia.
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DISSEMINATED INFECTIONS

• Frequently found in autopsy but is not usually
  clinically relevant.
• Heart myocardium and valves, prostate gland,
  kidneys, thyroid gland

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A 57 y-o patient with acute lymphoblastic
leukemia. Allogeneic BMT. Deep neutropenia and
abdominal pain. Abdominal CT showed
enterocholitis and ascitis Blood Scedosporium
prolificans
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Chest radiography showed bilateral
condensations. Blood Scedosporium
prolificans Autopsy confirmed disseminated
Scedosporium prolificans infection.
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CNS COMPLICATIONS

• Conscience level deterioration
• Focal neurologic deficit
• Haematologic spread
• Hyphae embolization from pulmonary infection

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CNS COMPLICATIONS

• 7 patients
• Bilateral hypodense lesions 5/7 patients
• Basal ganglia and internal capsule
• Corticomedullary junction
• Pathology Embolic infarctions caused by hyphae
  thrombus that obstruct large and
  intermediatesized vessels.

European Radiology 200616(2)496-502.
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CNS COMPLICATIONS

• Hemorrhage in 4 patients
• (Subarachnoid hemorrhage in two)
• No meningeal or ependymal enhancement
• 1 case of bilateral panuveitis by fungi
  infarction
• Rapid and fatal evolution in 6 of 7 patients

European Radiology 200616(2)496-502.
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A 37-y-o patient with AML and allogeneic BMT. Day
82 Mental deterioration. CT Multiple
hypodense lesions at basal ganglia with no mass
efect and no enhancement.
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Autopsy ( 2 days later) Embolic infarctions with
intraventricular and subarchnoid hemorrhage.
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BRAIN CT

• CNS infections are obscured during neutropenia,
  neuroimaging has a crucial role
• Cerebral scedosporiosis has a high affinity for
  perforating arteries, like aspergillosis.
• Different!
• Rapid and fatal evolution ( prevents sterile
  infarcts from being converted to septic infarcts)
• High frequency of hemorrhagic complications
  (fungal aneurysms?)

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A 52 y.o. female with multiple myeloma who
received an autologous BMT. A mycotic native
valve endocarditis was detected and Scedosporium
prolificans was isolated from blood cultures.
She suffered a sudden mental deterioration
and cranialCT scan showed intracranial
subarachnoid hemorrhage. Secondary vascular
invasion may result in a true fungal aneurysm and
subarachnoid hemorrhage.
Eur J Clin Microbiol Infect Dis. 2001
Mar20(3)215-7.
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• A 18 y.o female myelodisplastic syndrome who
  received a non-familial allogeneic BMT with
  severe neutropenia. Thorax radiography showed
  bilateral parenchymal condensations.
• Conscience level deterioration. Cranial CT
  depicted several ischemic cortical lesions and
  panuveitis.
• Autopsy revealed mycotic brain infarcts with
  hyphae. Autopsy findings haemorrhagic lesions in
  both lungs in whom branched hyphae were detected
  and multiple mycotic brain infarcts.

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A 66 y-o man with acute myeloblastic
leukemia. Scedosporium disseminated infection
from pulmonary lesions. Cranial CT showed two
hypodense lesions (frontobasal-not shown- and
cerebellum and one hemorrhagic cerebellar lesion.
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A 36 y-o patient with AML with allogeneic
BMT. Fever and deep neutropenia at 25day. Chest
radiography right lower neumonia. Brain CT
Right hemiparesis and conscience level
deterioration Death two days later. Necropsy
Scedosporium detected in right lung, heart,
liver, brain, kidneys, muscles, bone marrow)
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16 y-o patient with AML treated with allogeneic
BMT. Neurologic deterioration. Cranial CT showed
multiple hypodense ischaemic embolic lesions
MUCOR
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LAST CASE
5 y-o child with acute
lymphoblastic leukemia, allogeneic non-familial
bone marrow transplantation. Graft versus-host
disease. 27 day general deterioration,
diarrhea 13400 Leukocytes, EEG diffuse
encephalopathy
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95 day post transplantation disartria,
hemianopsia, hemiplegia.
9 august
12 august
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Chest CT showed bilateral patchy condensations,
not observed in chest radiography (low
sensitivity because low resolution)
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Treatment with cotrimoxazol, anfo-B, meropenem,
clindamicina and pirimetamina. 105 day
progressive deterioration of conscience level and
respiratory failure.
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105 day progressive deterioration of conscience
level and respiratory failure.
C
22 august
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• Multiorgan failure and death
• Death 25 august
• AUTOPSY
• Disseminated scedosporiosis. Calciphylaxia.
• CNS Intraparenchymal and intraventricular
  hemorrhage. Massive infiltration by hyphae
  (Scedosporium prolificans).

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CONCLUSIONS

• Scedosporium prolificans must be included in the
  differential diagnosis of fungal disseminated
  infections in immunocompromised patients.
• Imaging diagnosis of Scedosporium infections is
  non-specific.
• Early Chest CT and brain CT might help to detect
  prompt diagnosis of fungal infections in deep
  neutropenic patients

THANK YOU VERY MUCH FOR YOUR ATTENTION !
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• ACKNOWLEDGEMENTS
• Drs Agustín Gutiérrez, Andrés González Mandly,
  Consuelo Díez, Elena Sánchez, Radiology
• Drs Arancha Bermúdez, Mónica López-Duarte, and
  Fernando Marco Haematology
• Dr Fidel Fernández, Pathology
• Dr Ricardo Salesa, Microbiology
• José Ramón, secretario plus.