Lung, Brain, and Spinal Cord Abscesses After a Near-Drowning Episode

A 35-year-old man with a history of substance abuse was taken to the hospital after being rescued from a freshwater river where he had a near-drowning experience. He was treated in the Intensive Care Unit for aspiration pneumonia and had a favorable initial clinical course. On day 20 of the hospital stay, worsening cough and new left upper- and lower-extremity weakness were noted. Computed tomography showed bilateral lung cavitation and nodularity (Figure, A B), and a magnetic resonance imaging (MRI) scan revealed multiple lesions within the brain and cervical cord (Figure, C and D). Laboratory examination was notable for white blood cell count of 65.7 × 103/µL, platelets of 783 × 103/µL, C-reactive protein of 104 mg/L, and a serum (1,3)-ß-D-glucan (BDG) of 344 pg/mL. Blood and cerebrospinal fluid cultures were negative for bacteria, fungi, and mycobacteria. However, cultures of expectorated sputum were positive for Lomentospora prolificans and Scedosporium apiospermum (Figure, E-H), and later confirmed by DNA sequencing. The patient was treated with a combination of intravenous voriconazole, micafungin, and dexamethasone. Interval brain and spine MRI on day 25 after initiation of antifungals revealed a reduction in the size of the lesions, and the neurological examination showed improvement. He was discharged home on long-term oral voriconazole and terbinafine. Serum BDG became negative by day 57 of therapy. At 9 months of follow-up, the patient's upper-extremity weakness continues to improve, and repeat MRI shows resolution of the brain lesions and reduction in the size of the cervical cord lesion.