A 32 year-old-woman without past medical history, presented to emergency room for focal motor seizures of the right upper limb, happening thrice, with impaired awareness between the seizures. At admission, physical examination revealed a fever (39  C) and regular heartbeat. Neurologic examination showed a Glasgow Coma Scale score of 15/15 (Eye opening = 4, Verbal response = 5, Motor response = 6). The patient did not complain about headache, vomiting or neck stiffness, she was only drowsy without focal abnormalities. Seizures were controlled with Intra-Venous (I.V) then oral antiepileptic treatment (clonazepam and levetiracetam). The initial anamnesis found no history of seizures, neither signs of high intracranial pressure.
Laboratory findings revealed high leukocytes count (15.5 Giga/mm3) and elevated of C-reactive protein (70 mg/L). Brain Magnetic Resonance Imaging (MRI) showed a single round well circumcised lesion in the left frontal lobe, measuring 22*19 mm with low T1 and high T2 signal, heterogeneous with peripheral enhancement, with a distinctive high signal in Diffusion sequences, and ADC restriction in some areas (Fig. 1). These results were in favor of a brain abscess.
Extensive investigation found no history of immunologic deficiency, no susceptibility to infections, no diabetes, no intrauterine device, no injectable drugs use. However, the patient revealed that she was self-treating some "tooth pain" with only high doses of non-steroid anti-inflammatory three weeks before. Blood and urine culture were negative. A lumbar puncture (LP) was not performed, because of the raised intracranial pressure and the risk of cerebral herniation. Computed Tomography (CT) scan of chest, abdomen and pelvis showed no associated locations. Transthoracic and transesophageal cardiac sonography were normal. Serology for HIV, hepatitis B and C hepatitis and toxoplasmosis were negatives. Aspergillus antigenemia was also negative.
The patient was operated: a puncture of the abscess and a removal of the shell (complete resection) were performed through a small frontal craniotomy, with no postoperative complications.
Treatment began with antimicrobial drugs empirically (cefotaxime 18 g IV infusion/d), levofloxacin (500 mg IV 2x/d) and metronidazole (500 mg IV 3x/d).
Direct bacteriological and mycological exams were negative. PCR-Based Rapid Detection of Mycobacterium tuberculosis was also negative. After 24 h of culture on Chloramphenicol Sabouraud agar medium with and without Actidione at 37  C, white, creamy, flat, and shiny colonies appeared. C. glabrata was identified by VITEK  2 (Fig. 2). To test the sensitivity to antifungals, we used the automated VITEK  2 using the antibiotic susceptibility testing (AST) card. The antifungal susceptibility testing showed resistance to fluconazole and sensitivity to voriconazole, caspofungin, micafungin, amphotericin B and flucytosine. The Minimum Inhibitory Concentration (MIC) of voriconazole was 1 mg/L. Bacterial culture was negative.
Brain abscess due to C. glabrata without candidemia was diagnosed. Antifungal treatment began with voriconazole (400 mg [6 mg/kg] twice first day orally then 200 mg [3 mg/kg] twice daily). The clinical course was rapidly favorable with resolution of neurological symptoms. The patient had undergone subsequent MRI brain (on day 21) showing complete resolution of the rim-enhancing lesion, without evidence of residual or recurrent abscess. Antifungal treatment was stopped on the day 24 and the patient was discharged.