Fonsecaea monophora cerebral phaeohyphomycosis: case report of successful surgical excision and voriconazole treatment and review

We report a case of Fonsecaea monophora cerebral phaeohyphomycosis successfully treated with surgical excision and voriconazole monotherapy in a patient receiving maintenance immunosuppression therapy for 8 years after cadaveric renal transplantation. She presented with a severe frontal headache in the absence of any constitutional or neurologic symptoms. Brain magnetic resonance imaging showed an irregular 3.1 x 3.4 cm ring-enhancing lesion in her left frontal lobe. The patient underwent craniotomy and resection of her mass, with intraoperative spillage of some of her abscess contents into her lateral ventricle. Histopathology of her resected mass showed necrotic fragments of brain parenchyma with granulomatous inflammation and numerous pigmented fungal forms. A mold, recovered from cultures inoculated with portions of her brain resection specimen, was later definitively identified as Fonsecaea monophora. Initial serum (1 -> 3) beta-D-glucan (BG) levels exceeded 500 pg/ml. The patient received voriconazole, which she tolerated well, without recurrent headaches or abscess formation noted on serial brain imaging. Her BG declined to < 31 pg/ml one year following her abscess resection. She discontinued antifungal therapy after an 18-month treatment course, and has remained free of any clinical or radiographic evidence of recurrent abscess formation three years later.