Intracranial aneurysm secondary to mycotic orbital and sinus infection. Report of a case implicating penicillium as an opportunistic fungus

Ruptured fungal mycotic internal carotid artery aneurysm successfully treated with stent-assisted coil embolization: A case report

Background:

Ruptured intracranial fungal mycotic aneurysms have a high mortality rate. It has been reported that the number of opportunistic infections has increased. Here, we report the first case of a patient in which a ruptured fungal carotid artery aneurysm was successfully treated by stent-assisted coil embolization.

Case Description:

A 76-year-old male receiving dual antiplatelet therapy due to a recent percutaneous transluminal angioplasty presented with blurred vision of the right eye and diplopia. Magnetic resonance imaging revealed a fungal mass in the sphenoid sinus, and the patient was pathologically diagnosed with invasive aspergillosis. After receiving oral voriconazole for 4 weeks, he was admitted to the hospital with hemorrhagic shock from epistaxis. The right internal carotid artery angiography revealed a de novo irregularly shaped aneurysm at the cavernous portion, projecting into the sphenoid sinus, which was considered to be the source of bleeding. Due to the lack of ischemic tolerance and urgent demand for hemostasis, we performed a stent-assisted coil embolization of the aneurysm without interrupting the blood flow. Postoperatively, the patient had no neurological deficit, and treatment with voriconazole was continued for 12 months without rebleeding.

Conclusion:

Stent-assisted coil embolization without parent artery occlusion might be a promising option for the urgent treatment of ruptured fungal mycotic aneurysms. Long-term administration of voriconazole might be continued for 12 months for such patients.

Disseminated Staphylococcal Disease Complicated with Intracranial Internal Carotid Artery Mycotic Pseudoaneurysm and Cerebral Infarcts—A Rare Presentation in a Malnourished Child

A 2.5-year-old girl child patient with moderate malnutrition presented with right forehead abscess followed by ipsilateral orbital cellulitis. She also developed a left hydropneumothorax within a week. Subsequently she had left focal onset seizures with secondary generalized status epilepticus followed by development of left hemiparesis. Neuroimaging showed infarcts of varying ages in the right cerebral hemisphere and basal ganglia. Angiography revealed right internal carotid artery pseudoaneurysm. Blood and pus cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Investigations for immunodeficiency were negative. The patient received vancomycin intravenously for 6 weeks and intercostal tube drainage for hydropneumothorax. She was discharged with an antiepileptic drug and aspirin. There was complete resolution of the orbital cellulitis and hydropneumothorax and also the pseudoaneurysm on follow-up angiography 3 months later.

Talaromyces (Penicillium) Species Infection in the Central Nervous System

Talaromycosis typically occurs as an opportunistic infection among immunocompromised individuals. Infection caused by species other than T. marneffei is uncommon. While most reported cases describe infection in the lungs, we report an extremely rare intracranial Talaromyces species infection. This 61-year-old with end-stage renal disease who was unwell for the previous two months, presented with fever and worsening confusion lasting for three days. Lumbar puncture was suggestive of meningitis. Cerebrospinal fluid (CSF) culture was later confirmed to be Penicillium chrysogenum. The patient was co-infected with Group B Streptococcus sepsis. He improved with amphotericin B and ceftriaxone and was discharged with oral itraconazole for four weeks. However, he died of unknown causes two weeks later at home. Talaromyces species infection in the central nervous system is uncommon. This case highlighted a rare but life-threatening fungal meningitis. Among the four reported cases worldwide, none of the patients survived.

Fungal Internal Carotid Artery Aneurysm Treated by Trapping and High-Flow Bypass: A Case Report and Literature Review

We report a case of unruptured fungal internal carotid artery (ICA) aneurysm and review the pertinent literature. A 79-year-old man presented with decreased visual acuity on the right side, and he was diagnosed with retrobulbar optic neuritis. Medical treatment with steroids resulted in Aspergillus meningoencephalitis spreading to the bottom of bilateral frontal lobes, caused by an intracranial extension of sphenoid sinusitis. Magnetic resonance imaging (MRI) performed 26 days after the start of antifungal therapy showed a denovo right ICA aneurysm projecting anteriorly into the sphenoid sinus. As the aneurysm grew rapidly, it was trapped surgically after establishing a high-flow bypass from the external carotid artery to the middle cerebral artery. The patient's postoperative course was uneventful. Anti-fungal medication was continued until plasma concentrations of beta-D-glucan decreased to within normal limits. Although fungal ICA aneurysm carries a high mortality rate, early detection and prompt treatment by trapping and high-flow bypass can lead to good clinical outcome.

Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature

In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .

Fungal Mycotic Aneurysm in a Case of Acute Lymphoblastic Leukemia

We report a case of a 15-year old boy who was managed as a case of B cell lymphoblastic leukaemia with the modified BFM 90 protocol. During the induction phase, he developed febrile neutropenia with sino-pulmonary fungal infection confirmed on histopathology. He developed left sided hemiparesis during in-hospital management of febrile neutropenia. Neuroimaging revealed 9.6 × 8.4 mm round well defined aneurysm arising from right cortical artery in distal middle cerebral artery territory. He underwent fronto-temporo-parietal craniectomy with evacuation of the hematoma and excision of the aneurysm. Histopathological examination of excised aneurysmal specimen grew same species of fungus as was cultured from nasal scraping. He recovered fully in next 6 months with minimal residual focal neurological deficits. Presently he is in maintenance phase chemotherapy. We presented this case to illustrate a rare complication of ALL therapy with mycotic aneurysm secondary to invasive fungal infection treated successfully.

Multiple brain abscesses due to Penicillium spp infection

We present a case of central nervous system (CNS) infection by a member of the Penicillium genera in a HIV-negative man in Brazil. The patient was admitted complaining of loss of visual fields and speech disturbances. CT scan revealed multiple brain abscesses. Stereothacic biopsies revealed fungal infection and amphotericin B treatment begun with initial improvement. The patient died few days later as a consequence of massive gastrointestinal bleeding due to ruptured esophageal varices. The necropsy and final microbiologic analyses disclosed infection by Penicillium sp. There are thousands of fungal species of the Penicillium genera. Systemic penicilliosis is caused by the P. marneffei and was formerly a rare disease, but now is one of the most common opportunistic infection of AIDS patients in Southeast Asia. The clinical presentation usually involves the respiratory system and the skin, besides general symptoms like fever and weight loss. Penicillium spp infection caused by species other than P. marneffei normally cause only superficial or allergic disease but rare cases of invasive disease do occur. We report the fourth case of Penicillium spp CNS infection.

Mycotic intracavernous carotid aneurysm

Intracavernous carotid mycotic aneurysms are rare and management is dictated by clinical presentation. This case involved a patient presenting with a symptomatic expanding proximal internal carotid artery aneurysm treated with antibiotics and balloon occlusion but with thromboembolic complications resulting in a fatal outcome. Points of discussion include difficulties faced in reaching a diagnosis, management options for mycotic aneurysms and the rationale in this case for choosing endovascular rather than surgical treatment. The use and limitations of trial balloon occlusion are discussed as well as complications of vessel occlusion, in particular thromboembolism. Also discussed is the importance of surveillance imaging and the impact of sepsis on overall management.

Orbital pythiosis: a non-fungal disease mimicking orbital mycotic infections, with a retrospective review of the literature. Orbitale Pythiose: Eine nicht pilzbedingte, Orbitalmykose vortauschende Krankheit nebst Literaturubersicht

In the past decade there have been four well-documented cases of orbital pythiosis caused by Pythium insidiosum. All were recorded in apparently healthy children. Although pythiosis seems to be a rare infection in humans, we recently conducted a review of the medical literature to investigate misdiagnosed cases of orbital pythiosis in the past 100 years in children. To track putative cases of orbital pythiosis, we first identified orbital cases initially diagnosed as fungal infections. We were particularly interested in cases (a) involving apparently young healthy hosts, (b) the presence of hyaline, aseptate hyphal elements in the infected tissues, (c) the morphological features of the hyphal elements, (d) the presence of an eosinophilic granulomatous reaction with the Splendore-Hoeppli phenomenon around the mycelial elements, (e) resistance to antifungal therapy, (f) outcome after therapy, if any, and (g) cultural strategies. This study showed that indeed, there had been five other recorded cases of orbital infections, all in young children in the USA, with characteristics consistent with infections caused by P. insidiosum. The reports had described those cases of orbital-cranial-arterial diseases as patients with aspergillosis (one case), penicilliosis infection (one case), and zygomycosis (three cases). We reviewed those anomalous cases and discuss details about their clinical, pathologic, therapeutic, and etiologic evidence used to reclassify them as putative cases of orbital pythiosis.

Extracranial internal carotid artery Salmonella mycotic aneurysm complicated by occlusion of the internal carotid artery: depiction by color Doppler sonography, CT and DSA

Mycotic aneurysms of the extracranial carotid artery are rare. Seventy-four cases have been described in the medical literature and only eight secondary to Salmonella infection. To our knowledge, color Doppler sonography, computed tomography (CT), and digital subtraction angiography (DSA) findings relating to the diagnosis and follow-up of extracranial internal carotid artery mycotic aneurysm complicated by occlusion have not previously been described in the literature. We present a report of color Doppler sonography, CT, and DSA findings of a mycotic aneurysm of the right extracranial internal carotid artery due to Salmonella associated with occlusion of the internal carotid artery, promptly diagnosed and followed up using these imaging modalities.

Invasive infection due to penicillium species other than P. marneffei

Infection caused by Penicillium spp. due to species other than P. marneffei is rare. We present three such cases of invasive disease. The first had chronic granulomatous disorder (CGD) with pulmonary infection caused by Penicillium spp. and he responded to amphotericin B therapy. Cases two and three were not known to be immunocompromised and both failed to respond to therapy. Case two had cerebral disease from an unknown source caused by P. chrysogenum. Case three probably acquired infection caused by P. decumbens peri-operatively and presented with paravertebral infection. The pertinent literature on invasive infections of Penicillium spp. other than P. marneffei is reviewed. From 1951 onwards, 31 reported cases of invasive disease included 12 cases of pulmonary infection (six in non-immunocompromised patients), four cases of prosthetic valve endocarditis, six cases of CAPD peritonitis, five cases of endophthalmitis, individual cases of fungemia and oesophagitis (both in AIDS), upper urinary tract infection and intracranial infection. Trauma, surgery or prosthetic material is commonly implicated in the non-pulmonary cases. Superficial infection (keratitis and otomycosis) is commonly caused by Penicillium spp. Allergic pulmonary disease, often occupational (such as various cheeseworkers' diseases), is also common. Optimal therapy for invasive infection is not established, but surgery may be advisable if possible. Amphotericin B may be the most effective antifungal drug.

Pseudomonas aeruginosa causing a right carotid artery mycotic aneurysm after a dental extraction procedure

Mycotic aneurysms of the carotid arteries are rare. We describe a right carotid artery mycotic aneurysm in a 70-year-old man. His symptoms began immediately after a complicated molar extraction and persisted until the diagnosis was made and surgical resection and repair were undertaken. Pseudomonas aeruginosa was isolated from multiple blood cultures and excised tissues. We review another 73 cases uncovered by an extensive literature search. Bacteremia, recent surgery, head and neck infections, dental infections, and endocarditis are the most common predisposing conditions. Computed tomography and magnetic resonance imaging are techniques for accurately confirming the suspicion of any aneurysm, but angiography is the gold standard. Primary resection of the aneurysm with native vein interposition, in conjunction with prolonged antibiotic therapy, is the preferred strategy. A total of 6 cases thus far, including ours, have been clearly associated with dental surgical procedures. These cases are characterized by rapidly enlarging neck masses in the presence of fever. Microorganisms, particularly gram-negative rods, in contrast to normal oral flora, eg, streptococci and anaerobes, are often isolated. With prompt diagnosis and treatment, outcome is often satisfactory.

Penicillium peritonitis in a patient receiving continuous ambulatory peritoneal dialysis

We describe herein a case of peritonitis caused by Penicillium species in a patient receiving continuous ambulatory peritonal dialysis (CAPD). This is the first reported case of Penicillium peritonitis complicating CAPD. It is also unusual because Penicillium typically is considered a contaminant and only rarely is it considered a human pathogen.

Fatal necrotizing esophagitis due to Penicillium chrysogenum in a patient with acquired immunodeficiency syndrome

Although blue-green molds of the genus Penicillium are ubiquitous in the human environment, invasive penicilliosis is uncommon and primarily encountered among immunosuppressed patients. A patient with HIV infection who died of severe necrotizing esophagitis caused by Penicillium chrysogenum is reported and the relevant English language literature on human penicilliosis is reviewed. Although infectious esophagitis is commonly associated with AIDS, Penicillium esophagitis has not been described in such patients.

Mycotic (Aspergillus) arteritis resulting in fatal subarachnoid hemorrhage: a case report

A seventy-one year-old Japanese man suffering from carcinoma of the common bile duct died from subarachnoid hemorrhage secondary in intracranial mycotic arteritis (MA). Repeated cultures of the discharge from the draining tubes, the tip of intravenous hyperalimentation catheters, blood, sputum, and urine failed to grow any fungus. Autopsy disclosed MA due to Aspergillus at the terminal portion of the right internal carotid artery close to the posterior communicating artery.

Heavy contamination of operating room air by Penicillium species: identification of the source and attempts at decontamination

Increased rates of nosocomial infection caused by filamentous fungi in immunocompromised patients prompted microbiologic surveillance of the central air handling systems in our hospital. During a 4-year period, Penicillium species were isolated from 47 patients, including two with surgical wound infections caused by Penicillium. Counts of Penicillium in operating room air were much higher (195 colony-forming units [CFU]/m3) than in 95% filtered corridor air (14.6 CFU/m3; p less than 0.01). Ventilation ducts and terminal units lined with fiberglass in the operating room air handling system were heavily contaminated by Penicillium; the fiberglass was also contaminated with Aspergillus species. Corrective measures included filter replacement and decontamination of the ventilation system with aerosolized chlorine solution. Although operating room air remained free of filamentous fungi during the next 7 months, contamination eventually recurred and required repeated decontamination. We believe that certification guidelines are highly desirable for hospital ventilation systems, especially if the system serves immunocompromised patients.

Intracranial granuloma caused by Aspergillus fumigatus

A case is reported of intracranial granuloma caused by Aspergillus fumigatus involving the anterior cranial fossa and the frontal lobe. In this case, clinical symptoms developed about 5 years before the diagnosis was made. The final diagnosis was made by a craniotomy. The patient was treated with an extensive excision and chemotherapy, but finally he failed to respond to these treatments. We compile a summary of reported cases with a tabulation of pertinent information and discuss the pathogenesis, prognosis, and difficulty in treating this infection.

Bacterial aneurysms of the intracavernous carotid artery

✓ Six cases of bacterial intracavernous carotid artery aneurysms of extravascular origin secondary to cavernous sinus thrombophlebitis are reported along with a review of 12 similar cases collected from the literature. Of the authors' six cases, there were three children and three adults. Meningitis was found in five patients. All patients received prolonged antibiotic therapy. Spontaneous resolution of the aneurysm occurred in one patient, thrombosis of the internal carotid artery in another, and progressive enlargement of the aneurysm was seen on sequential angiography in the other two. Evidence of associated arteritis was present in all of the patients. Carotid ligation for persistent ophthalmoplegia was carried out in two patients, of whom one had a giant aneurysm and the other progressive aneurysm enlargement. The results of treatment were good in all cases. The authors believe that carotid arteriography is obligatory in cases of cavernous sinus thrombophlebitis in which ophthalmoplegia persists despite adequate antibiotic therapy.

Candidal infection in the central nervous system

Candida has become the most prevalent cerebral mycosis at autopsy, indicating a significant incidence coupled with inadequate eradication. Of 29 patients with systemic candidiasis, 48 percent (14 of 29) also had central nervous system involvement. Of these patients, however, only 21 percent (three of 14) had antemortem diagnosis, and only one of these three patients remains alive; the two patients with antemortem diagnosis who died had a meningeal form that, although easier to document on the basis of cerebrospinal fluid examination, is now distinctly rarer than other forms of the disease in adults. The lone surviving patient was treated with amphotericin B for endocarditis and mycotic aneurysms of the cerebral vessels. One clue to central nervous system candidal infection was the striking correlation between cardiac and cerebral involvement; 80 percent of patients with myocardial or valve infection also had central nervous system candidiasis. Most forms of immunosuppression represent a risk factor for both the systemic and cerebral mycoses. Neuropathologically, there is a spectrum of disease entities associated with Candida, including two previously unrecognized lesions reported herein: fungus balls of both white and gray matter and mycotic aneurysms secondary to Candida parapsilosis. Other parenchymal presentations include thrombosis, vasculitis, abscess, hemorrhage, and demyelination. For drug therapy such as amphotericin B to be more effective, earlier diagnosis of these parenchymal infections must be sought.

Cerebral aspergilloma

This is the report on a fatal case of aspergilloma with intracranial mycotic aneurysm associated with Aspergillus flavus infection, confirmed by culture and serology. Drug therapy is discussed.

Orbital aspergillosis: report of a case in a child

A child developed eyelid swelling that was diagnosed in succession as an abscess, eosinophilic granuloma, malignancy, and inflammatory pseudotumor. Treatment modalities included antibiotics, radiation and corticosteroids. Repeated histologic examination finally provided the diagnosis of orbital mycosis, most consistent with aspergillosis. Despite six weeks of therapy with Amphotericin B, an exenteration was required. Amphotericin B was continued for another six weeks, and there has been no evidence of recurrent disease after two years of follow-up. The problems encountered in the diagnosis and management of this unusual infectious disease of the orbit in children are discussed in detail.

Oral mycoses and their treatment

Mycoses of the mouth and nearby areas can be caused by both yeasts and filamentous fungi. They may appear either independently or as part of a systemic infection. It is typical of many mycoses that they occur as a consequence of local factors operating in the mouth, or in patients debilitated by severe diseases. Yeasts that are part of the normal microbial flora of man, among them especially Candida species, are the most frequent causative agents. Some tropical or semitropical infections may occur in Scandinavia and Finland, but they are rare. Local therapy with antimycotics is often effective in acute infections, whereas some chronic ones may make systemic administration necessary. Some of these infections are treated surgically.

Aspergillosis of the central nervous system

Aspergillosis of the central nervous system is rare. The spread to the CNS is usually from the lungs and uncommonly from paranasal sinuses. Four cases of CNS aspergillosis with spread of infection from the paranasal sinuses are described. Two patients had meningitis, one intracranial granuloma and one presented with subarachnoid haemorrhage resulting from a fungal mycotic aneurysm. Difficulties in establishing the diagnosis are discussed.

Cerebral mycotic aneurysm of fungal origin. Case report

A young man who had a long history of sinusitis developed subarachnoid hemorrhage and died. Autopsy showed a mycotic aneurysm of fungal origin at the junction of the right posterior cerebral and internal carotid arteries. Four of five reported cases of fungal aneurysm were due to Aspergillus infection.

Bacterial intracranial aneurysm

✓ The authors tabulate and analyze cases of bacterial intracranial aneurysm documented since 1954, and add four of their own. In 85 cases the overall mortality was 46%. Elimination of patients dying before reaching the hospital makes this figure spuriously low. Figures for patients hospitalized for endocarditis before neurological symptoms occurred suggest a true mortality of 80% from aneurysms that rupture and 30% if the aneurysm remains intact. Multiple reports of spontaneously resolving, enlarging, diminishing, multiple, and sequentially appearing aneurysms, all of which occurred in our fourth case, clarify the need for complete and sequential angiography. Computerized tomographic (CT) scanning in this disease has not been reported, but our experience with these scans demonstrates considerable potential value.

A protocol of complete cerebral angiography and CT scanning of these neurologically asymptomatic patients is proposed, in order to assess the true incidence of bacterial intracranial aneurysm, to learn more of its natural history, and to prevent some neurological catastrophes.

[Bilateral cerebral mycotic aneurysm in a child. Report of a case and review of the literature]

The case of a 6 year-old boy, who was hospitalized with the diagnosis of purlent meningits is reported. The CSF examination disclosed pleocytosis and the antibioticotherapy was instituded. The bilateral carotid angiography demonstrated an arterial aneurysm of the frontal ascendent artery with hematoma in the left side and another in the posterior temporal artery, in the right side. The patient was operated on because of the hematoma, in the left side. The condition of the patient in the post-operatory period deteriorated and the death ocurred. The post-mortem examination disclosed a sub-arachnoidal hemorrhage, fronto-temporal hematoma in the left side and a para-capsular hematoma in the right side. The histological examination of the central part of the right side. The histological examination of the central part of the hematoma revealed a dilated arterial walls with a supurative inflammatory process.

Sinusitis of the maxillary antrum

Twenty-four adults with clinical evidence of sinusitis were studied by 65 needle punctures of the maxillary antrum. Fourteen of 15 sinuses with normal transillumination and 19 of 26 that were dull had normal aspirates, whereas 24 of 24 that were opaque had abnormal aspirates (P less than 0.001). Marked mucosal thickening as determined radiologically (Water's view) was associated with abnormal aspirates whereas lesser mucosal thickening was not (P less than 0.001). In acute sinusitis, there was a strong correlation between high aspirate leukocyte counts (greater than 1000 per cubic millimeter) and infection as manifested by bacterial titers of greater than 10(5) per milliliter or the isolation of virus fungus (P greater than 0.001). Anterior-nasal-swab cultures correlated poorly with direct aspirate culters. Organisms frequently recovered from the sinus included Haemophilus influenzae, Strepto coccus pneumoniae, and anaerobic bacteria. Rhinovirus was recovered twice. Antibiotics were usedful in patients with acute sinusitis if the organism was sensitive in vitro (P less than 0.001).