First AD

Second AD

A 65-year-old female with sickle cell anemia and ESRD status postrenal transplant presenting with AMS and SIRS.

Figure 1 is two weeks prior to presentation. All other figures from current study.


Axial MR images through the cerebrum demonstrate new innumerable, well-circumscribed, subcentimeter foci of T2/FLAIR prolongation and restricted diffusion predominantly in the bilateral basal ganglia and at the gray-white matter junction, consistent with microabscesses. Few of the lesions demonstrate internal signal void on susceptibility images, consistent with associated hemorrhage. 


Disseminated military cerebral candidiasis is almost always caused by hematogenous spread with disseminated systemic infection. Clinical presentation typically includes lethargy and AMS of insidious onset. Risk factors for candidiasis include immunosuppression, hematologic malignancy, HIV/AIDS, long-term intravenous access, and treatment for bacterial sepsis. Candida albicans is the most frequent species involved. Mortality rates for disseminated candidiasis remain high, varying between 10% and 30%, even despite early initiation of aggressive antifungal therapy.

Candidiasis typically manifests as numerous supra and infratentorial microabscesses of less than 3 mm occurring at the corticomedullary junction, basal ganglia, and cerebellum. Macroabscesses and meningitis can occur, but are less common. Computerized tomography has a low sensitivity for detection of the microabscessses compared to MR. Magnetic resonance imaging of the microabscesses often demonstrates T1/T2 prolongation, enhancement, and restricted diffusion. Less commonly, the foci are associated with hemorrhage or infarction.

1. Starkey J, Moritani T, Kirby P. MRI of CNS Fungal Infections: Review of Aspergillosis to Histoplasmosis and Everything in Between. Clinical Neuroradiology. 2014;24:217-230.

2. Lin DJ, Sacks A, Shen J, Lee TC. Neurocandidiasis: a case report and consideration of the causes of restricted diffusion. Journal of Radiology Case Reports. 2013;7:1-5.
 

Image IQ

65-year-old female with sickle cell anemia and ESRD status postrenal transplant presenting with AMS and SIRS.

Image IQ: 65-year old female, Altered Mental Status, SIRS

Alex Heaton, MD

Erini Makariou, MD