Childhood Stroke as a Challenging Complication in Severe Systemic Mycosis

Background/Purpose: The etiology of arterial ischemic strokes in childhood is heterogeneous. Among the most common risk factors are cardiac causes, coagulopathies, and vasculopathies. Vasculopathies can arise, among others, as a result of (para-)infectious processes associated with bacterial or viral infections and rarely with mycosis.

Methods: A 10-year-old girl experienced a near-drowning accident in a lake. She recovered after successful resuscitation, hypothermia treatment, and antibiotic treatment for aspiration pneumonia. Later on, she developed an abscess-forming pneumonia, hematogenous osteomyelitis, and meningitis. Scedosporium apiospermum complex was cultivated from a bone biopsy. Lumbar puncture and cerebral MRI revealed intracranial involvement with meningoencephalitis and cerebral lesions, as well as neurovascular involvement with perivasculitis and multifocal vessel stenosis (carotid-T, basilar artery, P1 segment).

Results: The meningoencephalitic changes improved under intensive antifungal therapy, but the vasculitic changes progressed (further involving M1 segment, extra- and intracranial carotid arteries). The patient experienced recurrent and multifocal, clinically silent, ischemic strokes. Systemic vasculitis or underlying immunological disorders were ruled out. Steroids showed no therapeutic effect. The increasing vessel stenoses were attributed to the severe systemic mycosis, leading to adaptation and intensification of antifungal therapy under close monitoring. Severe side effects and toxicity necessitated a switch to an experimental treatment with new antifungal drugs (compassionate use). Subsequent ischemic lesions could be prevented.

Conclusion: In this case, childhood arterial ischemic stroke is discussed as a therapeutically challenging complication of severe systemic mycosis in scedosporiosis. Treatment is reserved for specialized centers with expertise in pediatric neurology, infectious diseases, hemostaseology, and neuroradiology—close collaboration is essential for treatment success.

Publication History

Article published online:
13 November 2023