Cerebral phaeohyphomycosis caused by Ramichloridium obovoideum (Ramichloridium mackenziei): Case report

OBJECTIVE AND IMPORTANCE: Only a few cerebral infections with the dark-wall ed mold Ramichloridium obovoideum (Ramichloridium mackenziei) have been rep orted in the literature. Central nervous system infections caused by this f ungus have poor prognoses; the optimal medical and surgical treatments have not yet been established. We report a case of cerebral R. obovoideum infec tion for which a combination of medical and surgical treatments failed. CLINICAL PRESENTATION: A 58-year-old Kuwaiti woman, with a history of chron ic renal failure requiring hemodialysis, presented with a 3-day history of left frontal headache, blurry vision, dizziness, and right-sided clumsiness . Computed tomography demonstrated multiple, ring-enhancing, cerebral lesio ns (the largest of which measured 2-3 cm) in the deep left parieto-occipita l region. INTERVENTION: A computed tomography-guided needle biopsy of the parieto-occ ipital lesion yielded 10 mi of dark caseous fluid. Stains demonstrated long , branching, septate hyphae. Fungal cultures grew R. obovoideum. The patien t was treated with a combination of amphotericin B and itraconazole. The co ndition of the patient continued to deteriorate, and stereotactic aspiratio n of the largest lesion was performed. Despite this approach, the lesion pr ogressed and the patient died. CONCLUSION: R. obovoideom is being increasingly recognized as a cause of ce rebral abscesses in patients residing in the Middle East. Prognoses are poo r, and responses to antifungal therapy are generally short-lived. Until mor e effective therapies are found, the greatest chance for adequate treatment involves early recognition, prompt treatment with antifungal agents, and a ttempts at complete resection.