# July 2026

- Link: https://isnr.in/july-2026/
- Published: 2026-07-10T12:10:48+05:30
- Author: ISNR

## **CASE HISTORY**

Patient of relapsed Early T cell precursor Acute lymphoblastic leukemia ( BM + testis).
He underwent Matched unrelated donor hematopoietic stem cell transplantation. He
relapsed in CNS 3 months post transplant and is on weekly triple IT for CNS relapse.
Now presented with altered sensorium and slurring of speach.

## Section Editors

Dr. Arpita Sahu, Dr. Sarbesh Tiwari, Dr. Sabha Ahmed,

Dr. Smily Sharma, Dr. Meena Nedunchelian

## Authors

Dr Prakhyath Gmabhira D

DNB resident, KMCH, Coimbatore.

Dr Kannan G,

Consultant, KMCH, Coimbatore

## Evaluation

Sepsis workup, cerebrospinal fluid analysis, and serum electrolytes were **normal**,
prompting evaluation for structural cause.

![](https://isnr.in/wp-content/uploads/2026/07/Picture-1.png)

**CT BRAIN:**

**Bilateral confluent subcortical white matter hypodensities (left > right), involving****
fronto****-parietal and temporal regions, with extension into the corpus callosum,
associated with mild mass effect.**

![](https://isnr.in/wp-content/uploads/2026/07/Picture-11.png)

**Diffuse infiltrative FLAIR hyperintense signal abnormalities involving:
 o Bilateral
fronto-parietal subcortical white matter (L > R) o Anterior temporal subcortical
white matter (L > R) o Left lentiform nucleus and external capsule o Periventricular
white matter (trigone region) o Bilateral basifrontal regions (L > R)

![](https://isnr.in/wp-content/uploads/2026/07/Picture-21.png)

**T2-weighted linear hypointense areas noted within the lesions.**

![](https://isnr.in/wp-content/uploads/2026/07/Picture-31.png)

![](https://isnr.in/wp-content/uploads/2026/07/Picture-41.png)

**Patchy areas of diffusion restriction with associated blooming on SWI in the left
frontal white matter.**

**Heterogeneous post-contrast enhancement involving the affected area are seen.**

![](https://isnr.in/wp-content/uploads/2026/07/isnr.png)

## **Significant reducedin cerebral blood volume (CBV) on perfusion imaging.**

**Imaging Differentials:**

**Angioinvasive**** fungal infection, likely invasive cerebral aspergillosis.**

**Other differentials- 1.leukemic infiltrates  2. PML**

**Diagnosis**

**High levels of ****Glactomannan**** in Bronchoalveolar lavage confirms Angio invasive
cerebral ****aspergilosis**

![](https://isnr.in/wp-content/uploads/2026/07/Picture-1-1.png)

**TREATMENT STARTED- INJECTION VARICONOZOLE.**

After 1 week- SENSORIUM AND SPEECH IMPROVED.

ADVISE- CONTINUE ANTIFUNGAL.

Continued on voriconazole for 2 weeks and came for follow-up

![](https://isnr.in/wp-content/uploads/2026/07/Picture-2.png)

Interval increase in the patchy areas of diffusion restriction with peripheral SWI
blooming are seen in left frontal lobe

![](https://isnr.in/wp-content/uploads/2026/07/Picture-3.png)

Peripheral  enhancement are seen in left frontal lobe corresponding to areas of 
involvement, – likley evolving abscess.  MRS shows a prominent lipid-lactate peak.

**FURTHER TREATMENT**

**Left frontotemporal craniotomy & excision biopsy done. Antifungal treatment continued.**

![](https://isnr.in/wp-content/uploads/2026/07/Picture-5.png)

## CONCLUSION:

| **Feature** | **Angioinvasive Aspergillosis** | **CNS Leukemic Infiltrates** | **Progressive Multifocal Leukoencephalopathy** | 
| **Pathophysiology** | Angioinvasion causing vessel occlusion, infarction, and hemorrhage. | CNS relapse with proliferation of leukemic blasts. | JC virus opportunistic infection destroying oligodendrocytes (demyelination). | 
| **Primary Location** | Corticomedullary junction, basal ganglia, thalami. | Leptomeninges, cranial nerves, parenchyma. | Asymmetric subcortical white matter (involves U-fibers). | 
| _Hemorrhage (SWI/T2)_* | **Prominent.** Blooming artifact due to micro/macro-hemorrhages. | Typically absent. | Absent. | 
| **Diffusion (DWI/ADC)** | **Central restriction** (due to ischemic/necrotic core). | Variable restriction (due to hypercellularity of blasts). | Usually absent (faint restriction possible at active advancing edge). | 
| **Enhancement (T1 C+)** | Ring or heterogeneous enhancement. | Leptomeningeal or solid parenchymal enhancement. | Non-enhancing (unless IRIS develops). | 
| **T2/FLAIR Signal** | “Target sign” (hyperintense core, dark rim, hyperintense edema). | Homogeneous hyperintensity. | Confluent, asymmetric hyperintensity. | 
| **T2 Internal Architecture** | **Linear/nodular hypointensities** (represents fungal elements and blood products). | Homogeneous. Lacks dark internal bands. | Homogeneous. Lacks dark internal bands. | 
| **Lab Diagnostics** | Elevated Galactomannan / Beta-D-glucan. | Positive CSF cytology / Flow cytometry for ALL blasts. | Positive JC Virus PCR in CSF. |

**Discussion**

●**Post-HSCT/Immunocompromised status.**

●**T2-Weighted Clues: Linear hypointense areas noted within the infiltrative lesions—
a classic sign of fungal hyphae or ****angioinvasive**** architecture.**

●**SWI (Susceptibility): Patchy areas of “blooming” in the left frontal white matter,
indicating micro-****hemorrhages****.**

●**DWI (Diffusion): Patchy areas of restricted diffusion, suggesting acute infarction
or high cellularity.**

●**Heterogeneous enhancement with mass effect.**

●**Perfusion Imaging: No significant increase in Cerebral Blood Volume (CBV), helping
to differentiate from high-grade neoplastic processes.**

**REFERENCE:**

**1.Matis GK, ****Voultsinou**** D, ****Chrysou**** O, ****Birbilis**** T, ****Geroukis****
T. Cerebral aspergillosis and acute myeloid ****leukemia****. J ****Neurosci****
Rural ****Pract****. 2013 Aug;4(****Suppl**** 1):S134-5. ****doi****: 10.4103/0976-
3147.116459. PMID: 24174784; PMCID: PMC3808046.**

**2.1.Machaj W, ****Korbecki**** A, ****Bińczyk**** W, ****Siudek**** B, ****Ussowicz****
M, Zimny A. Atypical radiological presentation of fatal invasive cerebral aspergillosis
in a patient with acute lymphoblastic ****leukemia**** after allogeneic bone marrow
transplant: A case report. Radiology Case Reports [Internet]. 2025 Jun 26;20(9):
4590–3. Available from: ****[https://www.sciencedirect.com/science/article/pii/S1930043325005266](https://www.sciencedirect.com/science/article/pii/S1930043325005266)**

**3.Chantelot, L., ****Sitterlé****, E., ****Poirée****, S. et al. Cerebral Aspergillosis:
Diagnostic Challenges, Therapeutic Strategies, and Future Research. CNS Drugs 40,
43–58 (2026). https://****doi.org****/10.1007/s40263-025-01241-0.**

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