Scedosporium apiospermum: An Emerging Fatal Cause of Fungal Abscess and Ventriculitis after Near-drowning

Herein, we describe a fatal case of central nervous system (CNS) pseudallescheriasis following near-drowning. A 13-year-old boy, who had been successfully resuscitated after near-drowning, presented with a transient episode of mental confusion during a hospital stay after recovering from severe aspiration pneumonia and respiratory failure. A magnetic resonance imaging (MRI) scan of the brain showed a small brain abscess in the left basal ganglia and ventriculitis in the left lateral ventricle. The brain abscess and ventriculitis did not respond to 4 weeks of antibiotic treatment and appeared even worse on a follow-up MRI. A diagnosis of CNS pseudallescheriasis was only possible with invasive stereotactic biopsy and aspiration of the abscess that showed the presence of hyphae and Scedosporium apiospermum. CNS pseudallescheriasis did not respond to multiple combinations of antifungal agents, including amphotericin B, isoconazole, itraconazole, and voriconazole. Two ventricular drainages and insertion of Ommaya reservoirs with intraventricular injection of voriconazole were insufficient to halt the infection. The patient passed away from sudden septic shock 2 months after identification of the brain abscess and ventriculitis. The patient's diagnosis was delayed because multiple examinations of the cerebrospinal fluid did not show positive cultures and could only be obtained from the aspirates of stereotactic biopsy. Physicians should be aware of CNS pseudallescheriasis associated with near-drowning because of the difficulty of diagnosis and the high mortality rate (70%) owing to poor responses to currently available antifungal agents.