Atypical presentation of a central nervous system aspergillosis in a peripheral T cell lymphoma patient
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LETTER TO THE EDITOR
Atypical presentation of a central nervous system aspergillosis in a peripheral T cell lymphoma patient Mathieu Larroquette 1 & Nahéma Issa 1 & Frédéric Gabriel 2 & Fabrice Camou 1 Received: 9 June 2020 / Accepted: 9 July 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear editor, A 73-year-old woman without any significant medical history was referred in an intensive care unit for febrile aplasia. Neither bacterial nor viral infection was detected in blood and fluids analyses. Biochemical analyses suggested hemophagocytosis features (ferritin = 33,128 ng/L, triglycerides = 3.71 g/L, and lactate dehydrogenase = 682 U/L). A PET/CT revealed a diffuse bone marrow infiltration, as well as the presence of abnormal supra- and infra-diaphragmatic lymph nodes. A bone marrow biopsy was performed, showing a lymphoid infiltration by a peripheral T cell lymphoma (CD3+, CD4+, CD5+, and CD7−), not otherwise specified. Chemotherapy with cyclophosphamide, doxorubicin, vincristine, etoposide, and prednisone (CHOEP protocol) was initiated immediately. Following 1 week of apparent clinical improvement, the patient showed signs of Brown-Sequard syndrome, accompanied by an increasing fever, and she was diagnosed with paraplegia within 2 days. MRI showed a T2 intramedullary hyper-intense signal from vertebra C5 to T1 (Fig. 1). Cerebrospinal fluid (CSF) analyses revealed high lactate level (4.1 mmol/L), moderate elevated protein (43 mg/dL), normal glucose (2.4 mmol/L), and no pleocytosis (white blood cell count = 2/mm3). Due to the compatible aspect of the MRI with a specific inflammatory myelitis, the patient received methylprednisolone pulse therapy (1 g/day for 3 days). Finally, blood analyses were positive for Aspergillus galactomannan with an index at 1.822, although it was negative 10 days before, and cerebrospinal fluid (CSF) galactomannan was strongly positive with an index > 12. The
* Fabrice Camou [email protected] 1
Medical Intensive Care and Infectious Diseases Unit, Saint Andre Hospital - CHU BORDEAUX, Bordeaux, France
2
Mycology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
diagnosis of invasive aspergillosis was classified as “probable” according to the update of the consensus of the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC-MSG) [1]. Then, we performed a realtime PCR using LightCycler technology on CSF, which was positive for Aspergillus DNA. Treatment with voriconazole was initiated. Thoracic CT revealed no lesion related to aspergillosis. Unfortunately, neurological symptoms were getting worse with installation of a complete tetraplegia and severe sinus bradycardia. Due to the poor prognosis of the lymphoma and after a collegial discussion, a decision to forgo lifesustaining therapy was made. Supportive care was then initiated. Unfortunately, the patient died a few days later and her family objected to an autopsy. Non-culture-based methodologies have been developed to get quick diagnosis of invasi
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