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A case of cerebral pheohyphomycosis in an immunocompetent patient: emphasis on intraoperative findings.

A 42-year-old male, cook by profession and apparently immunocompetent presented with headache and altered sensorium of 2 weeks duration. Examination was unremarkable except for bilateral mild papilledema. Magnetic resonance imaging (MRI) showed a T1-weighted hypointense lesion in right parietal region. The lesion was intensively contrast enhancing with multiple small lesions surrounding the main lesion [Figure 1]. It was hyperintense on T2-weighted sequence and there was restriction on diffusion-weighted imaging (DWI) [Figure 1]. In view of altered sensorium he was taken up for surgery with a preoperative diagnosis of high grade malignancy. During surgery, aspiration of the lesion showed pus. The abscess wall was removed in total after defining a clear plane of cleavage between brain and abscess. The wall of abscess had multiple blackish spots. The frozen section of abscess wall revealed granulomas and multinucleated giant cells containing pigmented fungi. Loading dose of amphotericin B was given intraoperatively. Biopsy report confirmed the diagnosis of fungal infection, pheohyphomycosis [Figure 2]. Patient has received 1,500 mg. of amphotericin B and is on oral voriconazole, doing well at follow-up.