Intracranial invasive aspergillosis originating in the sphenoid sinus: a successful treatment with high-dose itraconazole in three cases

We report three cases of intracranial aspergillosis originating in the sphenoid sinus in immunocompetent patients. The patients presented with an orbital apex syndrome in that a unilateral loss of vision and cranial nerve III palsy were seen in all cases and a contralateral involvement was also seen in one case. Despite the initial treatment with a conventional dose of itraconazole (ITCZ, 200 mg/day), the neurological deficits failed to improve and the granulomatous inflammation was not suppressed. Therefore, we treated with a combination of a high dose of ITCZ at 500-1000 mg/day (16-24 mg/kg/day) and amphotericin B (AMPH-B) at 0.5 mg/kg/day, in conjunction with a pulse dose of methylprednisolone at 1000 mg/day. Two cases responded favorably in that the ocular movements completely recovered, and their maximum serum concentrations of the hydroxy ITCZ were 7816 ng/ml and 5370 ng/ml. However, the other case worsened, despite ITCZ treatment at 16 mg/kg/day, and the serum concentration of the hydroxy ITCZ was 3863 ng/ml. The surgical decompression of the cavernous sinus via an extradural approach was performed, and the dose of ITCZ was increased to 24 mg/kg/day. The resulting serum concentration of the hydroxy ITCZ was 4753 ng/ml, and the outcome of this case has been favorable. These results suggest that a high blood level of the hydroxy ITCZ (more than 4500 ng/ml) is a prerequisite for the successful treatment of intracranial aspergillosis and that the combination treatment of ITCZ with AMPH-B would be preferred. The concomitant use of steroid and/or surgical decompression should be considered, if the invasiveness is not well-controlled in spite of intensive medical therapy.

Trigeminal neuralgia caused by a pontine abscess: case report

OBJECTIVE AND IMPORTANCE

Various intracranial abnormalities, including infectious conditions, may manifest as trigeminal neuralgia.

CLINICAL PRESENTATION

A 33-year-old man presented with a 15-day history of right-sided facial pain and numbness. Neurological examination revealed diminished corneal reflex and facial sensation in the right V(1)-V(2) distribution. Magnetic resonance imaging revealed a contrast-enhancing lesion centered at the right pons with extension of the enhancement to the sphenoid sinus.

INTERVENTION

Broad-spectrum antibiotics were administered for 6 weeks. This resulted in alleviation of symptoms and resolution of the lesion as revealed by repeat magnetic resonance imaging.

CONCLUSION

Presentation of a pons abscess with trigeminal neuralgia is rare, and to the best of our knowledge has not been reported previously. The patient was treated successfully with antibiotics alone.

[Sinus cavernous syndrome caused by isolated aspergillosis of the sphenoid sinus]

Isolated aspergillosis of the sphenoid sinus is a rare condition that is frequently diagnosed at a late stage because of its nonspecific and varying symptomatology. We report the case of a 75-year-old diabetic woman with a long history of retroorbital pain before she developed a subacute cavernous sinus syndrome. Neuroimaging including CT scan and MRI suggested a malignant tumor involving the sphenoid sinus but the diagnosis of aspergillosis was made intraoperatively and by histopathological examination. Soon after surgical drainage of the sphenoid sinus and systemic anti-fungal drug therapy, both retroorbital pain and cavernous sinus syndrome had completely resolved. This case emphasizes the fact that invasive isolated sphenoid sinus aspergillosis must be considered in the list of lesions causing sinus cavernous syndrome.

[Cerebrospinal fluid rhinorrhea and Streptococcus equisimilis-related meningitis 16 years after a head injury]

A case of meningitis caused by Streptococcus Equisimilis and cerebrospinal fluid rhinorrhea, in which the head trauma occurred 16 years before, is presented. To the best of the author's knowledge this is the first case reported with such characteristics. Several precipitating factors could be responsible for the unusually late reopening of the fistula Streptococci equisimilis is an uncommon cause of the bacteremia. An appropriate antimicrobrial therapy against S. Equisimilis followed by surgical dural repair were performed.

Mucocele-like lesions of the sphenoid sinus with hypointense foci on T2-weighted magnetic resonance imaging

Lesions limited to the sphenoid sinus are relatively rare, and are obscure with respect to symptoms and physical findings. The differential diagnosis of isolated sphenoid sinus disease includes bacterial sinusitis, fungal infection, granulomatous inflammation, mucocele, and tumors. Magnetic resonance imaging (MRI) can provide information that closely reflects the composition of the tissues, sometimes permitting differentiation between pathologically distinct lesions showing similar density by computed tomography. We describe two cases involving mucocele-like lesions of the sphenoid sinus where preoperative MRI revealed a focus of hypointensity within the lesions. In both patients the sphenoid sinus was opened by a transnasal endoscopic approach, and diseased tissue corresponding to the hypointense area was removed under direct endoscopic vision. Histopathological diagnosis revealed colonies of Aspergillus in one case and necrotic granulation tissue without fungus in the other. We concluded that MRI is a crucial part of preoperative evaluation and that the transnasal endoscopic approach represents a safe and effective method for treating nonmalignant isolated sphenoid sinus disease.

Characteristics of bony erosion in allergic fungal rhinosinusitis

OBJECTIVES

Erosion of bone with or without extension of disease into adjacent anatomic spaces is observed among some patients with allergic fungal rhinosinusitis (AFRS). The objective of this report is to further define these findings as they relate to this disease.

STUDY DESIGN

Retrospective chart review of 142 patients with AFRS diagnosed using the Bent-Kuhn criteria. All patients were treated at a single institution.

RESULTS

Approximately 20% of patients with AFRS demonstrated bone erosion on CT scan. The ethmoid sinus was the most commonly eroded site. The orbit and anterior cranial fossa were the most common adjacent anatomic spaces to exhibit disease extension. Sinus expansion, not the specific organism identified, was associated with the presence of bone erosion. Surgical management with endoscopic techniques was successful for all patients without any major perioperative complications.

CONCLUSION

Bone erosion can be related to AFR. Recognition of this possibility is important because bone erosion can be interpreted as an indication of invasive pathosis. In the presence of bone erosion or disease extension, endoscopic techniques can be used to surgically manage this disease.

[Aspergillosis of the sphenoid sinus: presentation as a pituitary mass]

A rare manifestation of aspergillosis in the central nervous system is its invasion through the sphenoidal wall into the sella turcica representing itself as a pituitary mass. The symptoms may be headache, visual defect caused by compression of the chiasma, hypopituitarism and diabetes insipidus. In the majority of cases only the postoperative histology leads to the correct diagnosis. A case of invasive aspergillosis was reported here with the clinical picture of a pituitary tumor and without underlying immunodeficiency.

Isolated sphenoid sinus abscess: clinical and radiological failure in preoperative diagnosis. Case report and review of the literature

BACKGROUND

Isolated sphenoid sinusitis and abscess formation is a rare entity, which can lead to misdiagnosed or improperly treated patients and an unfavorable outcome. Invasion of the skull base and cavernous sinus usually causes cranial nerve palsies, suggesting a neoplasm at the initial presentation.

CASE DESCRIPTION

A case of isolated abscess in the sphenoid sinus is reported. The complete destruction of the clivus and its unexceptional radiological data, in addition to the absence of clinical and laboratory evidence of infection, led us to misdiagnose a possible clival chordoma during preoperative evaluation. The patient underwent an endonasal-transsphenoidal procedure for diagnosis and surgical removal. Surgical drainage and prolonged antimicrobial treatment resulted in complete clinical recovery.

CONCLUSION

Its close proximity to vital structures and slender bony structures may allow the infection to disseminate, with serious neurological complications. On the other hand, the variable clinical presentations and radiological data usually cause delayed or missed diagnosis in these cases. This emphasizes the importance of documentation of this unusual entity and its radiological manifestations.

Value of Ga-67 SPECT in monitoring the effects of therapy in invasive aspergillosis of the sphenoid sinus

PURPOSE

We report a case of invasive sphenoid sinus aspergillosis clinically presenting as a pituitary mass.

METHODS

After exploration via the trans-sphenoidal approach and subsequent treatment with amphotericin-B, Ga-67 brain SPECT was performed twice to monitor the therapeutic effect.

RESULTS

Three months after antifungal treatment, Ga-67 brain SPECT showed partial resolution of the lesion in the sella turcica region. The patient continued with fluconazole treatment for another 2 months and received another Ga-67 brain SPECT, which showed complete clearing of the previous lesion.

CONCLUSION

Ga-67 brain SPECT may play a potentially useful role in monitoring the therapeutic effect of treatment of invasive sphenoid sinus aspergillosis.

Ocular presentation and successful outcome of invasive sphenoid sinus aspergillosis in acute myelogenous leukemia

We report the case of a 73-year-old male with acute myelogenous leukemia, who progressively developed a cavernous sinus syndrome during the aplastic phase after induction chemotherapy. Although the clinical, serological and radiological findings suggested an invasive sphenoid sinus aspergillosis, endoscopic ethmoido-sphenoidectomy allowed definitive diagnosis of the infection. After surgery, fungal eradication and reversal of the neurophtalmological damage paralleled complete hematologic remission. The differential diagnoses of the patient ocular symptoms are discussed. Early recognition, prompt intervention and immunologic reconstitution are essential for successful outcome of paranasal mycoses in immunosuppressed patients.

Magnetic resonance image detection of coincidental sphenoid sinus aspergillosis and pituitary microadenoma: a potential surgical disaster

While localizing the microadenoma in a patient with Cushing's disease on magnetic resonance imaging (MRI), fungal granuloma of the sphenoid sinus was coincidentally detected. This helped in the proper management of sphenoidal disease before undergoing trans-sphenoidal removal of the microadenoma, thus averting the possible catastrophe of direct intracranial spread of aspergillus infection.

[Endoscopic treatment of sphenoid aspergilloma]

In recent years there has been an increase in fungal infections of the nose and paranasal sinuses, even though it is difficult to ascertain the incidence and prevalence of such disorders. The only information which can be drawn from the literature is that such infections are diagnosed in 6% to 13% of surgically treated chronic sinusitis. Aspergillus is the etiologic agent in approximately 80% of cases. Fungal infections are classified into two groups: non-invasive and invasive. The former includes mycetoma and allergic fungal sinusitis. The latter comprises the chronic indolent form, which presents slowly progressive bone erosion, and the fulminant form, which almost invariably carries a dismal prognosis. The maxillary sinus is involved in 80% of mycetomas, followed, in order of frequency, by the ethmoid and frontal sinus. Localization in the sphenoid sinus is exceedingly rare, with only 71 cases reported in the literature. Diagnosis of mycetoma is based on fungal cultures of nasal secretion (which are indeed of limited sensitivity, around 40%) and histological examination of the material removed from the sinus, which identifies the fungus in 80% of cases. CT and MR are highly sensitive diagnostic tools because of their ability to detect the presence of ferromagnetic substances (i.e. iron, magnesium and manganese) and calcium deposits in the diseased sinus. Four new cases of sphenoid mycetoma, treated with endoscopic surgery, are described. The advantages of the endoscopic approach compared to traditional techniques and the role of anti mycotic agents are also discussed.

Painless orbital apex syndrome from mucormycosis

A 66-year-old woman with a history of non insulin-dependent diabetes mellitus, hypertension, and hypothyroidism presented with a painless orbital apex syndrome without any sign of orbital cellulitis or acute systemic disease. Her blood glucose was mildly elevated, but there was no diabetic ketoacidosis. Neuroimaging revealed only mild sinus disease. Transnasal sphenoidal mucosal biopsy showed an inflammatory mass with cellular atypia on frozen sections, suggesting squamous cell carcinoma. However, review of the permanent sections showed broad, nonseptate hyphae consistent with mucormycosis. The patient was treated with a 3-month course of intravenous amphotericin B and no further surgery. Examination 3 months after presentation revealed complete resolution of her ocular motility deficits and partial resolution of her optic neuropathy. Mucormycosis should be suspected in any case of orbital apex syndrome, especially in the diabetic patient.

[Allergic fungal sinusitis: is this rare disease an allergy or infection?]

Allergic Fungal Sinusitis (AFS) is a newly recognized form of benign, non invasive sinusitis the histopathologic features of which are similar to those of allergic bronchopulmonary aspergillosis. AFS is a rare condition. However, because treatment and prognosis vary widely, it is important that this disorder be recognized and differentiated from chronic bacterial sinusitis and other forms of fungal sinusitis. AFS does not discriminate by age although it is primarily found in young adults. AFS patients are usually atopic, often having a history of asthma and nasal polyposis. Many have suffered from the symptoms of chronic sinusitis for years while others have had multiple sinus surgery. Radiographs reveal the involvement of multiple sinuses, often with bone destruction. Laboratory findings support an allergic state with a marked increase in eosinophilia and total IgE. At times RAST testing proves positive for fungi and immediate cutaneous reactivity to fungi is also present. Histologic review of the sinus contents reveals characteristic "allergic mucin", with numerous eosinophiles, Charcot-Leyden crystals and fungal hyphae, without any fungi tissue invasion. A wide variety of fungal agents has been implicated, although the majority belong the Dematiacee family. Those patients with allergic mucin but no documented fungi are indicated as having AFS-like syndrome. The pathogenesis of AFS is uncertain. There is controversy in the literature as to what role hypersensitivity (Gell and Coombs type I and type III responses) in infection play. To date current therapeutic recommendations include complete exenteration of all allergic mucin. Adjunctive, short-term systemic steroids often prove useful and nasal steroid spray should be continued for long term. Systemic antifungal agents are not recommended in AFS. Recurrence is common and thus close clinical, endoscopic and radiographic follow-up is important. The clinicopathologic features of one patient with AFS are reported and etiopathogenetic problems are discussed. The presented case showed a positive culture with negative immunological testing (RAST-positive and immediate cutaneous reactivity to fungal antigen), thus confirming the pathogenetic hypothesis of the saprophytic fungal growth in an atopic patient.

Parasellar Aspergillus granuloma extending from the sphenoid sinus: report of two cases

BACKGROUND

Sphenoid sinus aspergillosis is a rare disease known to show an aggressive course with high mortality. Early diagnosis, though difficult, is required to prevent lethal fungal meningoencephalitis.

CASE REPORT

We describe two cases of parasellar Aspergillus granuloma extending from the sphenoid sinus clinically indistinguishable from intracranial neoplasms. In the first patient, the fungus colony was visualized by computed tomography (CT) and magnetic resonance imaging (MRI) as a calcified concretion and total removal was curative. In the second patient, partial removal and subsequent antifungal therapy had minimal effect.

CONCLUSIONS

The prognosis of the patients with this disease depends on prompt surgical treatment before intradural invasion occurs, and CT and MRI are useful diagnostic maneuvers for detecting calcified Aspergillus colonies.

Aspergillus sphenoid sinusitis-induced orbital apex syndrome in HIV infection

BACKGROUND

Orbital apex syndrome due to aspergillus sphenoid sinusitis is a rare condition. Human immunodeficiency virus (HIV) infection has recently been reported in aspergillus orbital abscess. To the authors' knowledge this is the first reported association of HIV with the orbital apex syndrome.

METHODS

A 37-year-old HIV-infected man presented with headache, reduced vision and progressive ophthalmoplegia in the right eye. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed sphenoid sinusitis. Sphenoid sinus biopsy was performed.

RESULTS

Light microscopy revealed infiltrative branching septate fungal hyphae. Fungal culture isolated Aspergillus fumigatus.

CONCLUSION

Atypical fungal infection such as Aspergillus fumigatus sphenoid sinusitis should be suspected in HIV-infected patients with orbital apex syndrome.

Trans-superior meatal approach to the sphenoid sinus

We have recently operated on patients with isolated lesions of the sphenoid sinus using the trans-superior meatal approach that we developed. This may be one of the least traumatic methods for treating the isolated lesions of the sphenoid sinus. Though it has a few limitations, this approach provides a direct and safe short-cut to the sphenoid sinus and is well tolerated by the patient under local anesthesia. We present our experience with transnasal trans-superior meatal approach to the sphenoid sinus and introduce the technique with case reports.

Functional endoscopic sinus surgery for isolated sphenoid sinus disease

BACKGROUND

This article reviews 12 cases of isolated sphenoid sinus disease: chronic inflammatory sinusitis (7), mucoceles (2), aspergillus lesions (2), and isolated polyp (1).

METHODS

Criteria for diagnosis were based on clinical symptoms, nasal endoscopic evaluation, and computed tomography (CT). Magnetic resonance imaging was used only in cases of bone erosion and when patients presented with vision problems. All patients were treated by functional endoscopic sphenoidotomy. Any postoperative complications were noted.

CONCLUSION

The reported good results, on the basis of regression of functional symptoms and with nasal endoscopic and CT evaluation, suggest that intranasal sphenoidotomy under endoscopic control is a safe and effective method of treatment of nonmalignant isolated sphenoid disease. The mean follow-up is 26 months.

Destructive noninvasive paranasal sinus aspergillosis: component of a spectrum of disease

A chronic, destructive form of paranasal sinus aspergillosis may exist without evidence of tissue fungal invasion. In this state, the pathogen results in progressive, chronic inflammation intermediate between previously described saprophytic and invasive states. We report three such cases. This variety of aspergillosis and an analysis of the clinical and histopathologic findings of previously reported cases support the concept that infection with the organism may produce a spectrum of pathologic changes and is akin to the range of aspergillosis disease states described affecting the lung. We classify paranasal and nasal aspergillosis as (1) noninvasive, either an aspergilloma or allergic type, (2) destructive, noninvasive, and (3) invasive, either slowly progressive or fulminant. Any form may progress to, or be associated with, more aggressive disease.

Case report: allergic aspergillosis of the sphenoid sinus: pitfall on MRI

Recent reports indicate that fungal sinusitis is more common than previously thought. Four different histological subtypes of Aspergillus sinusitis are now recognized. Fulminant Aspergillosis is usually seen in immunosuppressed patients, and chronic invasive Aspergillus sinusitis, allergic Aspergillus sinusitis and Aspergilloma are seen in the non-immunocompromised individual. We present a case of progressive unilateral visual loss in a 30-year-old woman. The unusual magnetic resonance findings and the value of computed tomography are discussed.

Five cases of mucormycosis in paranasal sinuses

Five cases of mucormycosis are reported, 2 of them suffered from immunosuppression, the other 3 did not. We conclude that a combination of CT and bacteriological findings is useful for the diagnosis of mucormycosis differentially from other diseases. Therapy consisted of paranasal debridement and administration of amphotericin B.

Clinical features of human infection with Scedosporium inflatum

We report on 17 Australian cases of human infection or colonization with Scedosporium inflatum. The spectrum of clinical manifestations was similar to that in infection caused by Scedosporium apiospermum. The patients were classified into three groups. Four immunocompetent patients who presented with localized infections of a joint, nail bed, eye, or sphenoidal sinus made up the first group. Our first case, in a boy with posttraumatic septic arthritis, responded to surgical drainage with amphotericin B followed by treatment with itraconazole. The other three cases were cured by surgery alone. The second group consisted of five immunocompromised patients who presented with disseminated infections in a variety of sites. Four of these patients did not respond to antifungal therapy and died. The fifth apparently responded to antifungal drugs after correction of his neutropenia. The third group included eight patients with asymptomatic colonization in the external ear (five cases) or respiratory secretions (three cases). The nine isolates of S. inflatum tested by both disk and agar dilution methods were resistant to antifungal drugs. In our first case, which responded clinically to itraconazole, the MIC of this drug for the fungal isolate was 25 micrograms/mL. Thus S. inflatum can cause a broad spectrum of human infections whose severity and prognosis depend largely on the host's immune status.

[A rare case of isolated aspergilloma of the sphenoid sinus]

The authors report an interesting case of an isolated pathology of the sphenoid sinus (more precisely, in this case a mycotic infection of this paranasal sinus), up to a few years ago an extremely rare disease and still today an exceptional entity in the clinical practice of an otolaryngologist. The investigations carried out indicated that the infection was caused by Aspergillus candidus, a fungus which only rarely becomes pathogenic in man. The paper reports the main anamnestic data as well as the clinical and instrumental assessment of the disease. It furthermore describes the surgical procedure employed, the relative reports obtained and supplies data concerning the microbiological tests carried out on the material removed and the histological pattern observed. The surgery had an excellent outcome: the patient was cured and showed no sign of recurrence of the disease. The discussion briefly presents the clinical picture created in man by Aspergillus and stresses the rarity of the disease, noting that, including the case in question, only 23 reports, documented with histological and microscopic data, have been made in literature. The AA affirm that to their knowledge this particular case of sphenoid sinusitis caused by Aspergillus candidus [correction of Candida] is the first ever to be reported and in conclusion underline the extreme care necessary in dealing with this pathology and in making a "quoad vitam" prognosis.

[Penicillinosis of the paranasal sinuses]

A 29-year old female patient suffering from severe pain in her right eye, headache, ophthalmoplegia and ptosis of the right eye, total roentgenological opacity of the right maxillary sinus and ethmoidal cells , as well as signs of bone destruction in the orbital floor, was operated on under the suspicion of a tumour. Histological and bacteriological examinations as well as fungus cultures indicated, however, that the patient was suffering from a chronic infection caused by Penicillium notatum. Surgical treatment and postoperative intravenous administration of amphotericin B resulted in complete recovery of the patient.