A 44-year-old female patient sought the neurosurgery service at Hospital Santa Paula with a complaint of lower back pain associated with paraparesis for 2 years with progressive worsening of the condition between crises. She reported development of paraplegia in the past year.
In an investigation of multiple hospital admissions, she previously underwent treatment for CNS fungal infection and neurotuberculosis in late 2020 with amphotericin B (for 6 weeks) followed by voriconazole (for 4 weeks) with an ineffective result. The cerebrospinal fluid (CSF) contained 43 cells (75% lymphocytes, monocytes 22%, macrophages 3%), protein 175 mg/dL; glucose 26 mg/dL; lactic acid 42 mg/dL; lactate dehydrogenase 30 U/L; adenosinedeaminase 6.2 U/L; gamma globulin 31.62%; microbiology negative; antibodies for syphilis, Borrelia burgdorferi, toxoplasmosis, cytomegalovirus (CMV), herpes simplex 1 and 2, herpes zoster, cysticercosis, human immunodeficiency virus (HIV), and human T-lymphotropic virus were not reactive; no cancerous cells were identified. She also presented a history of seizures and meningitis.
On neurological examination, the patient presented with dysarthria, horizontal nystagmus with preservation of extrinsic eye movement, Grade III strength in upper limbs with wrist spasticity, plegia in lower limbs, and anesthesia from the T12 level without proprioception. She also presented with bicipital, tricipital, and styloradial hyperreflexia in upper limbs, with bilateral exaltation points and positive Hoffmann's sign, besides patellar and aquilean areflexia, and negative Babinski's sign.
For better evaluation, magnetic resonance imaging (MRI) images of the brain and spine were requested. Brain MRI showed thickening and leptomeningeal impregnation by gadolinium compromising both lateral fissures, insula, and frontotemporal operculum, evidencing diffuse pachymeningitis [Figure 1]. The MRI of the spine showed marked diffuse leptomeningeal enhancement along the anterior and posterior pial surfaces of all medullary segments, as well as medullary cone, marked segmental narrowing of the medulla at T10-T11 levels with hypersignal in the weighted sequences at T1 and T2/STIR associated with the tumefactive effect of the cone spinal cord with intramedullary lesion at this level, hypointense in T1-weighted image and hyperintense in T2/STIR weighted [Figure 2].
From the imaging findings and their relationship with the clinic, the patient underwent surgery and biopsy of the lesion. A T10-T11 laminectomy was performed and, after straight opening of the dura mater, a whitish lesion was found in the intramedullary region, suggestive of an abscess, being, therefore, drained and biopsied for analysis [Figure 3].
The culture of the surgical specimen tested positive for C. albicans and the histopathological evaluation of the lesion revealed extensive fibrinoid material and presence of hyaline septate pseudohyphae and fungal spores, with strong impregnation by Grocott methenamine silver stain [Figure 4]. These findings are consistent with intramedullary abscess due to C. albicans infection, being the second case report in the literature.