Ciclosporin/dexamethasone/mycophenolate

Abstract

Cutibacterium acnes associated intracerebral abscess: case report A woman in her later 60s’ [exact age not stated] developed Cutibacterium acnes (C. acnes) associated intracerebral abscess during immunosuppressive treatment with ciclosporin, mycophenolate and dexamethasone. The woman, who had a history of bilateral lung transplantation, was followed up for chronic obstructive pulmonary disease in August 2017. She also had a history of mild headaches for many years. Post-transplant, her headaches progressed and were attributed to chronic migraine or use of analgesics pre-transplant. Hence, in December 2017, she was treated with valproate with a favorable result. At the same time, MRI showed limited old ischaemic lesions. She also had a history of hypercholesterolaemia, peripheral vascular disease and arterial hypertension. She had been receiving immunosuppressive therapy with ciclosporin, mycophenolate and dexamethasone [routes and dosages not stated]. In August 2019, she was consulted because of the worsened headache for the previous 3 months. Her headache also became more localized frontally. The MRI showed new abnormalities with an intense contrast-enhancing lesion in the genus of the corpus callosum and the right frontal lobe. Also, hyperintensity at the edges and extensive perilesional oedema was observed. Initially, lymphoma, another tumour or progressive multifocal leukoencephalopathy was suspected. The fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) revealed hypometabolism in the lesion, which ruled out the possibility of lymphoma or post-transplant lymphoproliferative disorder. The fluoro-ethyl-tyrosine PET-CT indicated glioma due to moderately increased amino acid metabolism. However, the CSF examination ruled out the possibility of glioma. Therefore, a stereotactic brain biopsy was done, and anatomopathological examination revealed elevated cellularity with a prominent inflammatory process. Stains for periodic acid-Schiff, Ziehl, polyomavirus and Grocott were negative. No evidence of the glial or lymphocytic tumoral process was observed. The reexamination of MRI after one month showed a further volume increase of oedema and lesion. The second biopsy was performed with deeper sampling at the hypodense centre of the abscess, which showed mixed inflammatory infiltrate with histiocytes and neutrophils with focal non-necrotising granulomas. The repeat stain tests again showed negative results. No signs of malignancy were observed. Fourteen days after the sampling, the culture showed a positive result for C. acnes, which was sensitive for clindamycin and penicillins [penicillin]. Based on the findings, a diagnosis of C. acnes associated intracerebral abscess was made [duration of treatments to reaction onset not stated]. No extracranial focus of C. acnes infection was observed. Hence, the woman’s treatment with mycophenolate was interrupted, and the woman started receiving unspecified antibiotic treatment, which initially consisted of a combination of clindamycin and ceftriaxone. Treatment with high-dose dexamethasone was tapered. Subsequently, radiographic examination showed a quick favorable clinical response, and after two weeks of treatment, the MRI revealed a remarkable decrease in abnormalities. Her radiographic findings gradually improved. She received ceftriaxone for 8 weeks. and clindamycin for 6 months. In view of favourable infectious evolution, her treatment with mycophenolate was restarted after six months. Additional follow-up after one year was scheduled.