Imaging of Fungal Infections of the Brain

  • Subhendu ParidaEmail author


Cell-mediated immunity is the primary line of defense against fungal infections; in immunocompromised patients, invasive infections occur in various organ systems including the central nervous system (CNS). In the CNS, meningeal and parenchymal disease can occur. The pathological hallmark of fungal infections is angioinvasion; it can explain several manifestations of the disease. Imaging closely follows the pathological changes.

Yeasts like Candida and Cryptococcus produce leptomeningitis commonly; hyphal organisms like Aspergillus spp. and Mucor spp. produce granulomas and abscesses. Vascular invasion can lead to stenosis, thrombosis, and mycotic aneurysm formation.


Magnetic resonance imaging Fungal infections Fungal granuloma Fungal abscess Mycotic aneurysm 



Central nervous system


Cerebrospinal fluid


Computed tomography


Digital subtraction angiography


Diffusion tensor imaging


Diffusion-weighted imaging




Fluid-attenuated inversion recovery


Human immunodeficiency virus-acquired immunodeficiency syndrome


Magnetic resonance imaging


Magnetic resonance spectroscopy


Magnetization transfer


Positron emission tomography-computed tomography


Parts per million


Susceptibility-weighted imaging




  1. Ahuja GK, Jain N, Vijayaraghavan M, Roy S. Cerebral mycotic aneurysm of fungal origin: case report. J Neurosurg. 1978;49(1):0107–10.Google Scholar
  2. Almutairi BM, Nguyen TB, Jansen GH, Asseri AH. Invasive aspergillosis of the brain: radiologic-pathologic correlation. Radiographics. 2009;29(2):375–9.PubMedGoogle Scholar
  3. Ankrah AO, Sathekge MM, Dierckx RA, Glaudemans AW. Imaging fungal infections in children. Clin Transl Imaging. 2016;4(1):57–72.PubMedPubMedCentralGoogle Scholar
  4. Antulov R, Dolic K, Fruehwald-Pallamar J, Miletic D, Thurnher MM. Differentiation of pyogenic and fungal brain abscesses with susceptibility-weighted MR sequences. Neuroradiology. 2014;56(11):937–45.PubMedGoogle Scholar
  5. Bariola JR, Perry P, Pappas PG, Proia L, Shealey W, Wright PW, Sizemore JM, Robinson M, Bradsher RW Jr. Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era. Clin Infect Dis. 2010;50(6):797–804.PubMedGoogle Scholar
  6. Buxi TB, Prakash K, Vohra R, Bhatia D. Imaging in phaeohyphomycosis of the brain: case report. Neuroradiology. 1996;38(2):139–41.PubMedGoogle Scholar
  7. Chimelli L, Mahler-Araújo MB. Fungal infections. Brain Pathol. 1997;7(1):613–27.PubMedGoogle Scholar
  8. Cornely OA, Arikan-Akdagli S, Dannaoui E, Groll AH, Lagrou K, Chakrabarti A, Lanternier F, Pagano LI, Skiada A, Akova M, Arendrup MC. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of mucormycosis 2013. Clin Microbiol Infect. 2014;20:5–26.PubMedGoogle Scholar
  9. Costa CH, Ribeiro JC, Nunes-Filho LP, Rabelo MG, Almeida-Neto WS. Soap bubble appearance in brain magnetic resonance imaging: cryptococcal meningoencephalitis. Rev Soc Bras Med Trop. 2013;46(5):658–9.PubMedGoogle Scholar
  10. Fennelly AM, Slenker AK, Murphy LC, Moussouttas M, Desimone JA. Candida cerebral abscesses: a case report and review of the literature. Med Mycol. 2013;51(7):779–84.PubMedGoogle Scholar
  11. Figueiredo SM, Campolina S, Rosa CA, Gontijo M, Tirone T, Assunção CB, Freire TF, Christo PP, Caligiorne RB. Cerebral macroabscess caused by Candida albicans in an immunocompetent patient: a diagnostic challenge. Med Mycol Case Rep. 2014;3:17–9.PubMedPubMedCentralGoogle Scholar
  12. Filizzola MJ, Martinez F, Rauf SJ. Phaeohyphomycosis of the central nervous system in immunocompetent hosts: report of a case and review of the literature. Int J Infect Dis. 2003;7(4):282–6.PubMedGoogle Scholar
  13. Gupta RK, Kathuria MK, Pradhan S. Magnetization transfer MR imaging in CNS tuberculosis. Am J Neuroradiol. 1999;20(5):867–75.PubMedGoogle Scholar
  14. Gupta RK, Jobanputra KJ, Yadav A. MR spectroscopy in brain infections. Neuroimaging Clin. 2013;23(3):475–98.Google Scholar
  15. Hauck EF, McGinnis M, Nauta HJ. Cerebral phaeohyphomycosis mimics high-grade astrocytoma. J Clin Neurosci. 2008;15(9):1061–6.PubMedGoogle Scholar
  16. Herrera DA, Dublin AB, Ormsby EL, Aminpour S, Howell LP. Imaging findings of rhinocerebral mucormycosis. Skull Base. 2009;19(2):117.PubMedPubMedCentralGoogle Scholar
  17. Horger M, Hebart H, Schimmel H, Vogel M, Brodoefel H, Oechsle K, Hahn U, Mittelbronn M, Bethge W, Claussen CD. Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation. Br J Radiol. 2006;79(945):e88–95.PubMedGoogle Scholar
  18. Hudgins PA, Baugnon KL. Head and neck: skull base imaging. Neurosurgery. 2017;82(3):255–67.Google Scholar
  19. Hurst RW, Judkins A, Bolger W, Chu A, Loevner LA. Mycotic aneurysm and cerebral infarction resulting from fungal sinusitis: imaging and pathologic correlation. Am J Neuroradiol. 2001;22(5):858–63.PubMedGoogle Scholar
  20. Kamran S, Bener AB, Alper D, Bakshi R. Role of fluid-attenuated inversion recovery in the diagnosis of meningitis: comparison with contrast-enhanced magnetic resonance imaging. J Comput Assist Tomogr. 2004;28(1):68–72.PubMedGoogle Scholar
  21. Kandpal H, Aneesh MK, Seith A, Sharma S. Symptomatic perineural extension of fungal sinusitis in an immunocompetent person: imaging features. Singap Med J. 2008;49(7):171–4.Google Scholar
  22. Katchanov J, Branding G, Jefferys L, Arastéh K, Stocker H, Siebert E. Neuroimaging of HIV-associated cryptococcal meningitis: comparison of magnetic resonance imaging findings in patients with and without immune reconstitution. Int J STD AIDS. 2016;27(2):110–7.PubMedGoogle Scholar
  23. Koc Z, Koc F, Yerdelen D, Ozdogu H. Rhino-orbital-cerebral mucormycosis with different cerebral involvements: infarct, hemorrhage, and ophthalmoplegia. Int J Neurosci. 2007;117(12):1677–90.PubMedGoogle Scholar
  24. Kourbeti IS, Mylonakis E. Fungal central nervous system infections: prevalence and diagnosis. Expert Rev Anti-Infect Ther. 2014;12(2):26.Google Scholar
  25. Kumar D, Nepal P, Singh S, Sheoran R, Bansal SK, Patil S. CNS aspergilloma mimicking tumors: review of CNS aspergillus infection imaging characteristics in the immunocompetent population. J Neuroradiol. 2018;45(3):169–76.PubMedGoogle Scholar
  26. Laine FJ, Nadel L, Braun IF. CT and MR imaging of the central skull base. Part 2. Pathologic spectrum. Radiographics. 1990;10(5):797–821.PubMedGoogle Scholar
  27. Lee EK, Lee EJ, Kim S, Lee YS. Importance of contrast-enhanced fluid-attenuated inversion recovery magnetic resonance imaging in various intracranial pathologic conditions. Korean J Radiol. 2016;17(1):127–41.PubMedPubMedCentralGoogle Scholar
  28. Lee SC, Dickson DW, Casadevall A. Pathology of cryptococcal meningoencephalitis: analysis of 27 patients with pathogenetic implications. Hum Pathol. 1996;27(8):839–47.PubMedGoogle Scholar
  29. Liu BX, Dai XJ, Liu H, Gong HH, Wang YX, Zhang LL. Cerebellar cryptococcosis characterized by a space-occupying lesion in an immunocompetent non-HIV patient. Neuropsychiatr Dis Treat. 2015;11:21.PubMedGoogle Scholar
  30. Liu Y, Wu H, Huang F, Fan Z, Xu B. Utility of 18F-FDG PET/CT in diagnosis and management of mucormycosis. Clin Nucl Med. 2013;38(9):e370–1.PubMedGoogle Scholar
  31. Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, Husain M, Singh S, Behari S, Gupta RK. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. Am J Neuroradiol. 2007;28(7):1332–8.PubMedGoogle Scholar
  32. Mandava P, Chaljub G, Patterson K, Hollingsworth JW. MR imaging of cavernous sinus invasion by mucormycosis: a case study. Clin Neurol Neurosurg. 2001;103(2):101–4.PubMedGoogle Scholar
  33. Marzolf G, Sabou M, Lannes B, Cotton F, Meyronet D, Galanaud D, Cottier JP, Grand S, Desal H, Kreutz J, Schenck M. Magnetic resonance imaging of cerebral aspergillosis: imaging and pathological correlations. PLoS One. 2016;11(4):e0152475.PubMedPubMedCentralGoogle Scholar
  34. Mathur M, Johnson CE, Sze G. Fungal infections of the central nervous system. Neuroimaging Clin N Am. 2012;22(4):609–32.PubMedGoogle Scholar
  35. McLean FM, Ginsberg LE, Stanton CA. Perineural spread of rhinocerebral mucormycosis. Am J Neuroradiol. 1996;17(1):114–6.PubMedGoogle Scholar
  36. Michael MA, Rushovich AM, Ciric I. Magnetic resonance imaging of cerebral aspergillosis. Comput Radiol. 1985;9(2):85–9.Google Scholar
  37. Moja M, Muthuphei MN, van der Westhuizen LR, Gledhill RF. Multiple infarcts in a patient with cerebral phaeohyphomycosis: CT and MRI. Neuroradiology. 2000;42(4):261–6.PubMedGoogle Scholar
  38. Moll GW, Raila FA, Liu GC, Conerly AW. Rhinocerebral mucormycosis in IDDM: sequential magnetic resonance imaging of long-term survival with intensive therapy. Diabetes Care. 1994;17(11):1348–53.PubMedGoogle Scholar
  39. Muraoka S, Araki Y, Izumi T, Takeuchi K, Okamoto S, Wakabayashi T. Cerebral infarction and subarachnoid hemorrhage caused by central nervous system Aspergillus infection. World Neurosurg. 2016;90:705–e9.PubMedGoogle Scholar
  40. Murthy JM, Sundaram C, Prasad VS, Purohit AK, Rammurti S, Laxmi V. Sinocranial aspergillosis: a form of central nervous system aspergillosis in south India. Mycoses. 2001;44(5):141–5.PubMedGoogle Scholar
  41. Nath K, Husain M, Trivedi R, Kumar R, Prasad KN, Rathore RK, Gupta RK. Clinical implications of increased fractional anisotropy in meningitis associated with brain abscess. J Comput Assist Tomogr. 2007;31(6):888–93.PubMedGoogle Scholar
  42. Neves N, Santos L, Reis C, Sarmento A. Candida albicans brain abscesses in an injection drug user patient: a case report. BMC Res Notes. 2014;7(1):837.PubMedPubMedCentralGoogle Scholar
  43. Nithyanandam S, Correa MA. Rhino-orbital mucormycosis and aspergillosis: differences in outcome, clinical and imaging characteristics. Eur Arch Otorhinolaryngol. 2010;267(1):161–2.PubMedGoogle Scholar
  44. Offiah CE, Naseer A. Spectrum of imaging appearances of intracranial cryptococcal infection in HIV/AIDS patients in the anti-retroviral therapy era. Clin Radiol. 2016;71(1):9–17.PubMedGoogle Scholar
  45. Oner AY, Celik H, Akpek S, Tokgoz N. Central nervous system aspergillosis: magnetic resonance imaging, diffusion-weighted imaging, and magnetic resonance spectroscopy features. Acta Radiol. 2006;47(4):408–12.PubMedGoogle Scholar
  46. Orguc S, Yücetürk AV, Demir MA, Goktan C. Rhinocerebral mucormycosis: perineural spread via the trigeminal nerve. J Clin Neurosci. 2005;12(4):484–6.PubMedGoogle Scholar
  47. Raz E, Win W, Hagiwara M, Lui YW, Cohen B, Fatterpekar GM. Fungal sinusitis. Neuroimaging Clin. 2015;25(4):569–76.Google Scholar
  48. Safder S, Carpenter JS, Roberts TD, Bailey N. The “black turbinate” sign: an early MR imaging finding of nasal mucormycosis. Am J Neuroradiol. 2010;31(4):771–4.PubMedGoogle Scholar
  49. Schwartz S, Kontoyiannis DP, Harrison T, Ruhnke M. Advances in the diagnosis and treatment of fungal infections of the CNS. Lancet Neurol. 2018;17(4):362–72.PubMedGoogle Scholar
  50. Scully EP, Baden LR, Katz JT. Fungal brain infections. Curr Opin Neurol. 2008;21(3):347–52.PubMedGoogle Scholar
  51. Shaikh AG, Sundararajan S. Angioinvasive aspergillosis of the central nervous system. Can J Neurol Sci. 2015;42(1):64–5.PubMedGoogle Scholar
  52. Shankar SK, Mahadevan A, Sundaram C, Sarkar C, Chacko G, Lanjewar DN, Santosh V, Yasha TC, Radhakrishnan VV. Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario. Neurol India. 2007;55(3):198.PubMedGoogle Scholar
  53. Sharma P, Mukherjee A, Karunanithi S, Bal C, Kumar R. Potential role of 18F-FDG PET/CT in patients with fungal infections. Am J Roentgenol. 2014;203(1):180–9.Google Scholar
  54. Sidani C, Freiser ME, Saigal G, Sklar E. Unusual case of cerebral aspergillosis with clinical and imaging findings mimicking lymphoma. Neuroradiol J. 2013;26(3):290–6.PubMedPubMedCentralGoogle Scholar
  55. Smirniotopoulos JG, Murphy FM, Rushing EJ, Rees JH, Schroeder JW. Patterns of contrast enhancement in the brain and meninges. Radiographics. 2007;27(2):525–51.PubMedGoogle Scholar
  56. Sravani T, Uppin SG, Uppin MS, Sundaram C. Rhinocerebral mucormycosis: pathology revisited with emphasis on perineural spread. Neurol India. 2014;62(4):383.PubMedGoogle Scholar
  57. Starkey J, Moritani T, Kirby P. MRI of CNS fungal infections: review of aspergillosis to histoplasmosis and everything in between. Clin Neuroradiol. 2014;24(3):217–30.PubMedGoogle Scholar
  58. Stavrakis C, Narayan A, Voronel O. Cerebral blastomycosis: radiologic-pathologic correlation of solitary CNS blastomycosis mass-like infection. J Clin Imaging Sci. 2015;5:30.PubMedPubMedCentralGoogle Scholar
  59. Sundaram C, Umabala P, Laxmi V, Purohit AK, Prasad VS, Panigrahi M, Sahu BP, Sarathi MV, Kaul S, Borghain R, Meena AK. Pathology of fungal infections of the central nervous system: 17 years’ experience from Southern India. Histopathology. 2006;49(4):396–405.PubMedGoogle Scholar
  60. Tempkin AD, Sobonya RE, Seeger JF, Oh ES. Cerebral aspergillosis: radiologic and pathologic findings. Radiographics. 2006;26(4):1239–42.PubMedGoogle Scholar
  61. Tore O, Akcaglar S, Kazak E, Heper Y, Akalin H, Hakyemez B, Ener B, Boekhout T, Hagen F. Multiple intracranial abscesses due to Cryptococcus neoformans: an unusual clinical feature in an immunocompetent patient and a short review of reported cases. Med Mycol. 2010;48(2):398–401.PubMedGoogle Scholar
  62. Tung GA, Rogg JM. Diffusion-weighted imaging of cerebritis. Am J Neuroradiol. 2003;24(6):1110–3.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of RadiologyCARE HospitalsHyderabadIndia
  2. 2.Department of NeurologyCARE HospitalsHyderabadIndia

Personalised recommendations