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. 2017 Nov-Dec;50(6):359-365.
doi: 10.1590/0100-3984.2016.0017.

Magnetic resonance imaging findings in central nervous system cryptococcosis: comparison between immunocompetent and immunocompromised patients

Stenio Bruno Leal Duarte  1 , Mariana Mari Oshima  1 , João Vitor do Amaral Mesquita  1 , Felipe Barjud Pereira do Nascimento  2 , Paula Christina de Azevedo  3 , Fabiano Reis  4
Affiliations

Magnetic resonance imaging findings in central nervous system cryptococcosis: comparison between immunocompetent and immunocompromised patients

Stenio Bruno Leal Duarte et al. Radiol Bras. 2017 Nov-Dec.

Abstract
in English, Portuguese

Objective: To assess the magnetic resonance imaging (MRI) patterns associated with central nervous system infection with Cryptococcus sp. in relation to patient immune status.

Materials and methods: This was a retrospective study of MRI data for 19 patients with neurocryptococcosis who underwent the examination between January 2000 and March 2014. The MRI characteristics examined included lesion topography, aspects of diffusion, T1-weighted images, T2-weighted images, and contrast enhancement patterns.

Results: In all cases, cryptococcal infection was confirmed by cerebrospinal fluid analysis. Of the 19 patients, 10 were immunocompromised and 9 were immunocompetent. Abnormal imaging patterns occurred alone or in conjunction with other manifestations. The imaging patterns found in immunocompromised patients included the following: leptomeningeal enhancement, in 6; pachymeningeal enhancement, in 3 (due to intracranial hypotension in 2); perivascular space involvement, in 4; granulomas, in 2; hydrocephalus, in 2; miliary nodules, in 1; and plexitis, in 1. In immunocompetent patients, the following imaging patterns were observed: leptomeningeal enhancement, in 5; perivascular space involvement, in 3; granulomas, in 3; cryptococcoma, in 1; ventriculitis, in 1; and hydrocephalus, in 1. In 2 immunocompetent patients, diffusion-weighted imaging showed diffusion restriction in cerebral cryptococcal granuloma.

Conclusion: In both groups, the most common imaging finding was leptomeningeal enhancement, followed by dilatation of perivascular spaces with the presence of mucoid material. Rare presentations, such as miliary nodules, plexitis, ventriculitis, and pachymeningeal enhancement, were also observed. None of the imaging patterns common to immunocompetent and immunocompromised patients differed significantly in frequency between them.

Objetivo: Avaliar os padrões de ressonância magnética (RM) associados à infecção do sistema nervoso central por Cryptococcus sp. em relação ao status imunológico dos pacientes.

Materiais e métodos: Dados de RM de 19 casos de neurocriptococose foram analisados retrospectivamente de janeiro de 2000 a março de 2014. As características de RM examinadas incluíram: sítio da lesão, aspectos em difusão, imagens ponderadas em T1 e T2 e padrões de realce pelo contraste.

Resultados: A infecção por Cryptococcus sp. foi confirmada pela análise do liquor em todos os casos. Dos 19 pacientes, 10 eram imunossuprimidos e 9 eram imunocompetentes. Os padrões de imagem anormais ocorreram isoladamente ou em associação com outras manifestações. Os padrões de imagem encontrados nos pacientes imunossuprimidos incluíram: realce leptomeníngeo (n = 6), realce paquimeníngeo (n = 3; 2 devidos a hipotensão intracraniana), envolvimento do espaço perivascular (n = 4), granulomas (n = 2), hidrocefalia (n = 2), nódulos miliares (n = 1) e plexite (n = 1). Em pacientes imunocompetentes, os padrões de imagem incluíram: realce leptomeníngeo (n = 5), envolvimento do espaço perivascular (n = 3), granulomas (n = 3), criptococoma (n = 1), ventriculite (n = 1) e hidrocefalia (n = 1). As sequências ponderadas em difusão mostraram restrição em 2 pacientes imunocompetentes com granulomas intracerebrais por criptococose.

Conclusão: O achado mais comum de imagem em ambos os grupos foi realce leptomeníngeo, seguido de dilatação dos espaços perivasculares pela presença do material mucoide. Apresentações raras como nódulos miliares, plexite, ventriculite e realce paquimeníngeo foram também observadas. Nenhum dos padrões de imagem comuns aos pacientes imunocompetentes e imunossuprimidos diferiu significativamente em frequência entre eles.

Keywords: Brain injuries/pathology; Central nervous system infections/diagnostic imaging; Cryptococcosis/diagnostic imaging; Diagnostic imaging; Magnetic resonance imaging; Meninges/pathology.

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Figures

Figure 1
Figure 1
Case 2. Contrast-enhanced coronal T1-weighted image showing supratentorial and infratentorial focal enhancement (black arrows). In this case, there is also diffuse pachymeningeal enhancement (white arrow), due to intracranial hypotension.
Figure 4
Figure 4
Case 4. Contrast-enhanced axial T1-weighted image showing bilateral choroid plexus thickening and enhancement at the ventricular atrium, mainly on the left side. In this case, pachymeningeal enhancement (due to intracranial hypotension) is also observed.
Figure 5
Figure 5
Case 7. Axial T2-weighted image (A) and axial T1-weighted image (B) showing bilateral dilated perivascular spaces (arrows).
Figure 7
Figure 7
Case 19. Proton magnetic resonance spectroscopy of the core of the lesion tissue showing a lactate peak at 1.3 ppm and multiple signals in the region of 3.6–3.8 ppm (arrows) corresponding to trehalose.
Figure 2
Figure 2
Case 9. Contrast-enhanced axial T1-weighted image showing mild hydrocephalus. There is also focal pachymeningeal enhancement adjacent to the left parietal lobe.
Figure 3
Figure 3
Case 5. Contrast-enhanced T1-weighted image showing miliary punctate enhancement at the centrum semiovale and at the cortico-subcortical junction (arrows).
Figure 6
Figure 6
Case 18. Cryptococcoma. Sagittal T1-weighted image showing a lesion with a heterogeneous, hypointense signal in the superior vermis (A). Axial T2- weighted image of the same lesion (B) showing a heterogeneous hyperintense signal and perilesional edema.
See this image and copyright information in PMC

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