Objective and importance: Only a few cerebral infections with the dark-walled mold Ramichloridium obovoideum (Ramichloridium mackenziei) have been reported in the literature. Central nervous system infections caused by this fungus have poor prognoses; the optimal medical and surgical treatments have not yet been established. We report a case of cerebral R. obovoideum infection for which a combination of medical and surgical treatments failed.
Clinical presentation: A 58-year-old Kuwaiti woman, with a history of chronic 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 lesions (the largest of which measured 2-3 cm) in the deep left parieto-occipital region.
Intervention: A computed tomography-guided needle biopsy of the parieto-occipital lesion yielded 10 ml of dark caseous fluid. Stains demonstrated long, branching, septate hyphae. Fungal cultures grew R. obovoideum. The patient was treated with a combination of amphotericin B and itraconazole. The condition of the patient continued to deteriorate, and stereotactic aspiration of the largest lesion was performed. Despite this approach, the lesion progressed and the patient died.
Conclusion: R. obovoideum is being increasingly recognized as a cause of cerebral abscesses in patients residing in the Middle East. Prognoses are poor, and responses to antifungal therapy are generally short-lived. Until more effective therapies are found, the greatest chance for adequate treatment involves early recognition, prompt treatment with antifungal agents, and attempts at complete resection.