Central nervous system infection: imaging findings suggestive of a fungus as the cause

Fungal infections of the central nervous system (CNS) are rare. However, because of the increase in the number of immunocompromised individuals, they have been gaining prominence in the differential diagnosis of CNS infections. Imaging techniques are sensitive for detecting and localizing an abnormality, in many cases allowing the origin of a lesion to be categorized as infectious, inflammatory, neoplastic, or vascular. This essay illustrates the magnetic resonance imaging and computed tomography findings of the most common fungal infections of the CNS, based on the experience of the Radiology Department of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, RS, Brazil.

Keywords:
Central nervous system fungal infections/diagnostic imaging; Mycoses/diagnosis; Brain abscess/diagnostic imaging; Tomography, X-ray computed; Magnetic resonance imaging

Authorship

Lillian Gonçalves Campos Correspondence: Dra. Lillian Gonçalves Campos. Hospital de Clínicas de Porto Alegre. Rua Ramiro Barcelos, 2350, Santa Cecília. Porto Alegre, RS, Brazil, 90035-903. Email: lilliancamposradiologia@gmail.com.

Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.Hospital de Clínicas de Porto AlegreBrazilPorto Alegre, RS, BrazilHospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.

https://orcid.org/0000-0002-5064-7190

Thaylla Maybe Bedinot da Conceição

Medvia Diagnóstico, Porto Alegre, RS, Brazil.Medvia DiagnósticoBrazilPorto Alegre, RS, BrazilMedvia Diagnóstico, Porto Alegre, RS, Brazil.

https://orcid.org/0000-0002-3083-1978

Marília Sfredo Krüger

Hospital Moinhos de Vento, Porto Alegre, RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre, RS, Brazil.

Hospital Municipal Getúlio Vargas, Porto Alegre, RS, Brazil.Hospital Municipal Getúlio VargasBrazilPorto Alegre, RS, BrazilHospital Municipal Getúlio Vargas, Porto Alegre, RS, Brazil.

https://orcid.org/0000-0001-6709-1451

Juliano Adams Perez

Hospital Moinhos de Vento, Porto Alegre, RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre, RS, Brazil.

https://orcid.org/0000-0002-5105-3116

Juliana Ávila Duarte

Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.Universidade Federal do Rio Grande do SulBrazilPorto Alegre, RS, BrazilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.

https://orcid.org/0000-0003-4973-2889

Correspondence: Dra. Lillian Gonçalves Campos. Hospital de Clínicas de Porto Alegre. Rua Ramiro Barcelos, 2350, Santa Cecília. Porto Alegre, RS, Brazil, 90035-903. Email: lilliancamposradiologia@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Medvia Diagnóstico, Porto Alegre, RS, Brazil.Medvia DiagnósticoBrazilPorto Alegre, RS, BrazilMedvia Diagnóstico, Porto Alegre, RS, Brazil.

Hospital Moinhos de Vento, Porto Alegre, RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre, RS, Brazil.

Hospital Municipal Getúlio Vargas, Porto Alegre, RS, Brazil.Hospital Municipal Getúlio VargasBrazilPorto Alegre, RS, BrazilHospital Municipal Getúlio Vargas, Porto Alegre, RS, Brazil.

Figures

Figures (10)

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Figure 1
Cryptococcosis meningitis. A: Contrast-enhanced axial T1-weighted MRI sequence showing leptomeningeal enhancement (arrow). B: Axial FLAIR sequence showing leptomeningeal hyperintensity.

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Figure 2
Axial FLAIR MRI sequence showing heterogeneous, predominantly hyperintense lesions in the basal nuclei, consistent with gelatinous pseudocysts (arrows), a classical finding of cryptococcosis of the CNS. Note also the granuloma in the choroid plexus (short arrow) and the hyperintense signal in the leptomeninges.

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Figure 3
Cryptococcomas caused by Cryptococcus gattii. Gadolinium contrastenhanced sagittal T1-weighted MRI sequence showing a hypointense lesion with peripheral ring enhancement in the bulb (arrow), with signs of edema in the surrounding tissues.

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Figure 4
A 55-year-old patient with mucormycosis in the sphenoid sinus. Axial T2-weighted MRI sequence showing central hypointensity and a hyperintense halo.

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Figure 5
Mucormycosis with orbital and brain involvement. A: Axial T2-weighted MRI sequence showing a hyperintense lesion, a hypointense peripheral halo (arrow), and pronounced peripheral edema. B: Contrastenhanced coronal T1-weighted sequence showing a heterogeneous lesion in the right orbital region. Black turbinate sign (thin arrow), characterized by a lack of enhancement of the nasal turbinate mucosa. There is also leptomeningeal enhancement on the affected side (thick arrow).

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Figure 6
A 20-year-old patient with angioinvasive aspergillosis of the CNS. A: Axial T1-weighted MRI sequence showing a hyperintense aspergilloma, with a hypointense halo, in the left occipital region (arrow). B: Axial T2-weighted sequence showing a hyperintense lesion (arrow).

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Figure 7
A 13-year-old immunocompromised patient with invasive aspergillosis of the CNS. A,B: Axial DWI and apparent diffusion coefficient map (arrows), respectively, showing restricted diffusion; C: Susceptibility-weighted imaging showing hemosiderin deposition (arrow); D: Contrastenhanced axial T1-weighted MRI sequence showing slight peripheral enhancement (arrow). Findings typical of fungal lesions caused by Aspergillus sp.

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Figure 8
Infarcts by vasculitis secondary to histoplasmosis in a 38-yearold, previously healthy, patient who had lived in caves full of bats in Palestine and presented with progressive dementia. Biopsy demonstrated vasculitis secondary to histoplasmosis of the CNS. A,B: Contrast-enhanced FLAIR MRI sequences showing hyperintense lesions in the basal ganglia, consistent with subacute stroke.

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Figure 9
Neuroparacoccidioidomycosis. MRI sequences—FLAIR (A), contrast-enhanced axial T1-weighted (B), and axial T2-weighted (C)—identifying an expansile lesion in the right parietal lobe. On the FLAIR and T2-weighted images, the lesion showed a hypointense signal with peripheral enhancement and vasogenic edema surrounding the lesion, as well as having an onion-skin appearance on the T2-weighted images.

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Figure 10
A 53-year-old alcoholic male patient, from a rural area, with a history of chewing grass. MRI showed granulomas in the CNS, suggestive of paracoccidioidomycosis. A: T2-weighted image showing lesions with heterogeneous low signal intensity in the cerebellum (arrows). B: Contrastenhanced T1-weighted image showing hypointense lesions with peripheral ring enhancement in the cerebellum (arrows).

Figure 1 Cryptococcosis meningitis. A: Contrast-enhanced axial T1-weighted MRI sequence showing leptomeningeal enhancement (arrow). B: Axial FLAIR sequence showing leptomeningeal hyperintensity.

Figure 2 Axial FLAIR MRI sequence showing heterogeneous, predominantly hyperintense lesions in the basal nuclei, consistent with gelatinous pseudocysts (arrows), a classical finding of cryptococcosis of the CNS. Note also the granuloma in the choroid plexus (short arrow) and the hyperintense signal in the leptomeninges.

Figure 3 Cryptococcomas caused by Cryptococcus gattii. Gadolinium contrastenhanced sagittal T1-weighted MRI sequence showing a hypointense lesion with peripheral ring enhancement in the bulb (arrow), with signs of edema in the surrounding tissues.

Figure 4 A 55-year-old patient with mucormycosis in the sphenoid sinus. Axial T2-weighted MRI sequence showing central hypointensity and a hyperintense halo.

Figure 5 Mucormycosis with orbital and brain involvement. A: Axial T2-weighted MRI sequence showing a hyperintense lesion, a hypointense peripheral halo (arrow), and pronounced peripheral edema. B: Contrastenhanced coronal T1-weighted sequence showing a heterogeneous lesion in the right orbital region. Black turbinate sign (thin arrow), characterized by a lack of enhancement of the nasal turbinate mucosa. There is also leptomeningeal enhancement on the affected side (thick arrow).

Figure 6 A 20-year-old patient with angioinvasive aspergillosis of the CNS. A: Axial T1-weighted MRI sequence showing a hyperintense aspergilloma, with a hypointense halo, in the left occipital region (arrow). B: Axial T2-weighted sequence showing a hyperintense lesion (arrow).

Figure 7 A 13-year-old immunocompromised patient with invasive aspergillosis of the CNS. A,B: Axial DWI and apparent diffusion coefficient map (arrows), respectively, showing restricted diffusion; C: Susceptibility-weighted imaging showing hemosiderin deposition (arrow); D: Contrastenhanced axial T1-weighted MRI sequence showing slight peripheral enhancement (arrow). Findings typical of fungal lesions caused by Aspergillus sp.

Figure 8 Infarcts by vasculitis secondary to histoplasmosis in a 38-yearold, previously healthy, patient who had lived in caves full of bats in Palestine and presented with progressive dementia. Biopsy demonstrated vasculitis secondary to histoplasmosis of the CNS. A,B: Contrast-enhanced FLAIR MRI sequences showing hyperintense lesions in the basal ganglia, consistent with subacute stroke.

Figure 9 Neuroparacoccidioidomycosis. MRI sequences—FLAIR (A), contrast-enhanced axial T1-weighted (B), and axial T2-weighted (C)—identifying an expansile lesion in the right parietal lobe. On the FLAIR and T2-weighted images, the lesion showed a hypointense signal with peripheral enhancement and vasogenic edema surrounding the lesion, as well as having an onion-skin appearance on the T2-weighted images.

Figure 10 A 53-year-old alcoholic male patient, from a rural area, with a history of chewing grass. MRI showed granulomas in the CNS, suggestive of paracoccidioidomycosis. A: T2-weighted image showing lesions with heterogeneous low signal intensity in the cerebellum (arrows). B: Contrastenhanced T1-weighted image showing hypointense lesions with peripheral ring enhancement in the cerebellum (arrows).

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Central nervous system infection: imaging findings suggestive of a fungus as the cause

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[1] Correspondence: Dra. Lillian Gonçalves Campos. Hospital de Clínicas de Porto Alegre. Rua Ramiro Barcelos, 2350, Santa Cecília. Porto Alegre, RS, Brazil, 90035-903. Email: lilliancamposradiologia@gmail.com.