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Cerebral mucormycosis: neuroimaging findings and histopathological correlation

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Abstract

Introduction

Mucormycosis are infections caused by molds of the order Mucorales. These opportunistic infections are rare, difficult to diagnose, and have a poor prognosis. We aimed to describe common radiographic patterns that may help to diagnose cerebral mucormycosis and search for histopathological correlations with imaging data.

Methods

We studied the radiological findings (CT and MRI) of 18 patients with cerebral mucormycosis and four patients’ histopathological findings.

Results

All patients were immunocompromised and/or diabetic. The type of lesions depended on the infection’s dissemination pathway. Hematogenous dissemination lesions were most frequently abscesses (59 lesions), cortical, cortical–subcortical, or in the basal ganglia, with a halo aspect on DWI for lesions larger than 1.6 cm. Only seven lesions were enhanced after contrast injection, with different presentations depending on patients’ immune status. Ischemia and hemorrhagic areas were also seen. Vascular lesions were represented by stenosis and thrombosis. Direct posterior extension lesions were bi-fronto basal hypodensities on CT and restricted diffusion without enhancement on MRI. A particular extension, perineural spread, was seen along the trigeminal nerve. Histopathological analysis found endovascular lesions with destruction of vessel walls by Mucorales, microbleeds around vessels, as well as acute and chronic inflammation.

Conclusions

MRI is the critical exam for cerebral mucormycosis. Weak ring enhancement and reduced halo diffusion suggest the diagnosis of fungal infections. Involvement of the frontal lobes should raise suspicion of mucormycosis (along with aspergillosis). The perineural spread can be considered a more specific extension pathway of mucormycosis.

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Abbreviations

ADC:

Apparent diffusion coefficient

CNS:

Central nervous system

CT:

Computed tomography

DWI:

Diffusion-weighted imaging

FLAIR:

Fluid-attenuated inversion recovery

GE:

Gradient-echo

L-AmB:

Liposomal amphotericin B

MRI:

Magnetic resonance imaging

W:

Weighted

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Author information

Author notes

  1. François Lersy and Julie Royer-Leblond have contributed equally to the work and are considered as co-first authors.

Authors and Affiliations

  1. Service d’imagerie 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière 67200, Strasbourg, France

    François Lersy, Agathe Chammas & Stéphane Kremer

  2. Service de Radiologie, Centre Hospitalier de Haguenau, Haguenau, France

    Julie Royer-Leblond

  3. Department of Pathology, Hautepierre University Hospital, 1 avenue Molière, 67200, Strasbourg, France

    Benoit Lhermitte

  4. Service de Médecine-Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

    Francis Schneider

  5. Service de Maladies Infectieuses, NHC, CHU de Strasbourg, Strasbourg, France

    Yves Hansmann & Nicolas Lefebvre

  6. CHU de Strasbourg, Laboratoire de Parasitologie Et de Mycologie Médicale, Plateau Technique de Microbiologie, 1 rue Koeberlé, 67000, Strasbourg, France

    Julie Denis & Marcela Sabou

  7. Université de Strasbourg, Institut de Parasitologie Et de Pathologie Tropicale, DIHP-UR 7292, Fédération de Médecine Translationnelle, 3 rue Koeberlé, 67000, Strasbourg, France

    Marcela Sabou

  8. Radiology Department, Rothschild Foundation in Paris, Paris, France

    François Lafitte

  9. Service de Radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, Lyon, France

    François Cotton

  10. Univ Lyon, INSA‐Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Pierre-Bénite, F‐69495, Lyon, France

    François Cotton

  11. INSERM, U1094, Neuroépidémiologie Tropicale, Limoges, France

    Marie-Paule Boncoeur-Martel

  12. Univ. Limoges, U1094, Neuroépidémiologie Tropicale, Institut D’Epidémiologie Et de Neurologie Tropicale, GEIST, Limoges, France

    Marie-Paule Boncoeur-Martel

  13. IRD, Unité Associée, Neuroépidémiologie Tropicale, Limoges, France

    Marie-Paule Boncoeur-Martel

  14. Service de Neuroradiologie, CHU Limoges, Limoges, France

    Marie-Paule Boncoeur-Martel

  15. CHU de Bordeaux, Neuro imagerie diagnostique et thérapeutique, 33000, Bordeaux, France

    Thomas Tourdias

  16. Univ. Bordeaux, INSERM U1215, Neurocentre Magendie, 33000, Bordeaux, France

    Thomas Tourdias

  17. Inserm U 1172, CHU de Lille, University of Lille, Lille, France

    Jean-Pierre Pruvo

  18. Department of Neuroradiology, CHU de Lille, University of Lille, Lille, France

    Jean-Pierre Pruvo

  19. Service de Radiologie, CHU Tours, Tours, France

    Jean-Philippe Cottier

  20. Department of Hematology, Institut de Cancérologie Strasbourg.Europe (ICANS) and Université de Strasbourg, Inserm UMR-S1113/IRFAC, Strasbourg, France

    Raoul Herbrecht

  21. Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France

    Stéphane Kremer

Authors
  1. François Lersy
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  2. Julie Royer-Leblond
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  3. Benoit Lhermitte
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  4. Agathe Chammas
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  5. Francis Schneider
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  6. Yves Hansmann
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  7. Nicolas Lefebvre
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  8. Julie Denis
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  9. Marcela Sabou
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  10. François Lafitte
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  11. François Cotton
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  12. Marie-Paule Boncoeur-Martel
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  13. Thomas Tourdias
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  14. Jean-Pierre Pruvo
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  15. Jean-Philippe Cottier
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  16. Raoul Herbrecht
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  17. Stéphane Kremer
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Contributions

FL, JRL, BL, RH, SK conception and design of the work, acquisition, analysis, and interpretation of data; drafting of the work; final approval; agreement to be accountable. Others: acquisition of data; critical review of the work; final approval; agreement to be accountable.

Corresponding author

Correspondence to Stéphane Kremer.

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Ethical approval

The study was approved as a retrospective non-interventional study by the ethical committee of Strasbourg University Hospital and was in accordance with the 1964 Helsinki Declaration and its later amendments.

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Lersy, F., Royer-Leblond, J., Lhermitte, B. et al. Cerebral mucormycosis: neuroimaging findings and histopathological correlation. J Neurol 269, 1386–1395 (2022). https://doi.org/10.1007/s00415-021-10701-8

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  • DOI: https://doi.org/10.1007/s00415-021-10701-8

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