Aspergillus mastoiditis, presenting with unexplained progressive otalgia, in an immunocompetent (older) patient

Long-Term Follow-Up of a Case of Probable Aspergillus Skull Base Osteomyelitis With Galactomannan Test and Literature Review

We report a probable case of Aspergillus basicranial infection diagnosed by pathogenic serological examination presenting atypical initial manifestations, and highlight the importance of serological examination to avoid treatment delay and disease management. An 84-year-old diabetic patient presented with right peripheral nerve palsy, intolerable otalgia, hearing loss, dysphagia, hoarseness, and bucking. The patient was diagnosed a probable Aspergillus skull base osteomyelitis with cranial neuritis and meningitis of central nervous system. Galactomannan test was used in combination with 1-3-β-D-glucan and magnetic resonance imaging to follow-up during the continuous treatment of voriconazole. To date, the patient has remained in clinical remission for over 39 months but the drug cannot be stopped safely.

Aspergillus infections of lateral skull base: a case series

PURPOSE

While extensive research with accurate classification has been done in mycoses of the paranasal sinuses and anterior skull base, a similar understanding of lateral skull base fungal pathologies is lacking due to relative rarity and diagnostic difficulties. We introduce a series of eleven cases and two different invasive entities of Aspergillus temporal bone diseases-fungal skull base osteomyelitis (SBO)/malignant otitis externa (MOE) and chronic invasive granulomatous fungal disease (CIGFD).

METHODOLOGY

A retrospective observational study was conducted at the neuro-otology unit of a tertiary care referral center between July 2017 and November 2022. Diagnosed cases of lateral skull base osteomyelitis with atypical symptoms and lack of response to culture-directed antibiotics were evaluated for fungal origin. Patient data, including history, laboratory findings, serum galactomannan assay, CT and MRI imaging findings, clinical examination findings, and co-morbidities, were analyzed. The treatment course and response were assessed.

RESULTS

A total of 11 cases were included in the study. Of these, 9 were cases of Aspergillus-induced skull base osteomyelitis (SBO) and 2 of Aspergillus-induced chronic invasive granulomatous fungal disease (CIGFD). CIGFD presented with persistent ear discharge and slowly progressive post-aural swelling, while all patients of fungal SBO had lower cranial nerve palsies. CIGFD responded to excision and antifungals, while SBO responded well to conservative anti-fungal treatment.

CONCLUSION

In cases of lateral SBO not responding to antibiotic therapy, the possibility of fungal etiology should be considered. Aspergillus spp. seems to be the major fungal pathogen.

A systematic review of antimicrobial treatment regimens and their outcomes in necrotising otitis externa

BACKGROUND

Necrotising otitis externa is a serious infection with minimal evidence underpinning its management. This review aims to synthesise published evidence of antimicrobial therapies and their outcomes in necrotising otitis externa.

METHODS

The review was PROSPERO registered (CRD42022353244) and conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses ('PRISMA') guidelines. A robust search strategy filtered 28 manuscripts into the final review. Antimicrobial therapy and clinical outcome data were extracted and analysed.

RESULTS

Published studies are heterogeneous, with high risk of bias and low certainty. Reporting of outcomes is poor and extremely variable. First-line therapy is most commonly in-patient (95 per cent) empiric fluoroquinolone (68 per cent) delivered intravenously (82 per cent). The lack of granular data and poor outcome reporting mean it is impossible to correlate treatment strategies with clinical outcomes.

CONCLUSION

Robust, consistent outcome reporting with reference to treatments administered is mandatory, to inform clinical management and optimise future research. Optimal antimicrobial choices and treatment strategies require clarification through prospective clinical trials.

Allergic Fungal Otomastoiditis: A Case Report

Otomastoiditis caused by an allergic reaction to fungi in the middle ear is rare, with only four cases reported in the English literature. We report the case of a patient with allergic fungal otomastoiditis. A 28-year-old man presented with otalgia, hearing loss, and vertigo. Exploratory tympanotomy revealed mucin with a peanut butter-like consistency and containing eosinophils and Candida parapsilosis, but no evidence of direct tissue invasion by fungi. The patient was treated with a combination of surgery and medication. Subtotal petrosectomy was finally performed to remove the middle ear mucosa and separate the middle ear from the external environment. Short-term prednisolone and long-term fluconazole were administered without satisfactory therapeutic results. The inflammatory condition has improved but continues without complete remission. Allergic fungal otomastoiditis is an extremely rare condition that may share pathophysiological features with allergic fungal rhinosinusitis, so a thorough examination combining bacterial cultures, histopathological examination with fungal staining, and serum antigen-specific immunoglobulin E against multiple fungi is essential. Optimal treatment probably comprises appropriate surgery and long-term administration of systemic corticosteroids. Definitive diagnostic criteria and therapeutic strategies need to be established, based on the accumulation of similar cases.

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Trends and Outcomes of Fungal Temporal Bone Osteomyelitis: A Scoping Review

INTRODUCTION

Temporal bone osteomyelitis is an invasive infection most often caused by bacteria and associated with high mortality. Fungal etiologies are rare and little is known of the predictors of disease severity and outcomes in fungal temporal bone osteomyelitis.

MATERIALS AND METHODS

A scoping review was performed to determine what is known from the literature on how clinical, diagnostic, and treatment characteristics relate to patient outcomes in fungal temporal bone osteomyelitis. Using PRISMA guidelines, three databases were searched to identify all published cases of fungal temporal bone osteomyelitis. Data were extracted from each study, including clinical, diagnostic, and treatment characteristics, and outcomes.

RESULTS

Sixty-eight studies comprising 74 individual cases of fungal temporal bone osteomyelitis were included. All studies were case reports. There were high rates of diabetes, facial nerve palsy, infectious complications, and need for surgical intervention, as well as a significant delay in the evaluation and diagnosis of fungal temporal bone osteomyelitis. Disease recovery was greater in patients presenting with otorrhea, comorbid diabetes, and in those without facial nerve palsy.

DISCUSSION

Many of the defining characteristics of fungal temporal bone osteomyelitis remain unknown, and future reports should focus on determining factors that improve timely diagnosis and treatment of fungal TBO in addition to identifying prognostic indicators for outcomes and survival.

Differential Diagnosis of Post Auricular Swelling with Mastoid Bone Involvement

Post auricular swelling with mastoid bone involvement most commonly occurs as a cranial complication of chronic or acute suppurative otitis media. Aim of this study, to detect etiology of postauricular swelling with mastoid bone involvement. This is a retrospective study which was done on all patients whom underwent mastoidectomy for post auricular swelling with mastoid bone involved in El Minia University Hospital from January 2014 to June 2017. A total of 49 patients were identified in this study, 23 males and 26 females, their ages ranged 5-28 years old with a mean of 25.8 years old. Group A: these were 45 patients with a history of otorrhea (chronic suppurative otitis media), of 3 months to 4 years duration. Group B: these were four patients without any history of otorrhea. Two patients diagnosed as acute otitis media, one patient diagnosed as Langerhans cell histiocytosis and one patient diagnosed as fungal mastoiditis. Chronic suppurative otitis media is the most common causes of postauricular swelling. Langerhans cell histiocytosis of the temporal bone and fungal mastoiditis are considered a rare presentation of postauricular swelling.

Mycology of chronic suppurative otitis media-cholesteatoma disease: An evaluative study

AIMS & OBJECTIVES

To detect the prevalence of fungus in chronic suppurative otitis media-cholesteatoma disease and to evaluate its clinical significance.

STUDY DESIGN

Prospective observational study conducted in a sample size of 46 patients at a tertiary care university teaching hospital.

MATERIALS & METHODS

Forty six patients suffering from chronic suppurative otitis media-cholesteatoma disease were recruited in this prospective study. Data was duly recorded. Cholesteatoma sample was procured at the time of mastoid surgery and microbiologically analysed for fungal infestation. Clinical correlation to fungus infestation of cholesteatoma was statistically analysed.

RESULTS

Out of the recruited 46 patients, post-operatively cholesteatoma was seen in 40 cases only. Seventeen i.e. 42.5% of these cases had fungal colonization of cholesteatoma. Further a statistically significant correlation between persistent otorrhoea and fungal infestation of cholesteatoma was observed. Three cases of fungal otomastoiditis were also recorded in this study, but a statistically significant correlation between complications and fungus infestation of cholesteatoma could not be clearly established.

CONCLUSIONS

There is fungal colonization of cholesteatoma which is pathogenic and can cause persistent otorrhoea.

Treatment of refractory Aspergillus otomycosis with voriconazole: case series and review

Background:

Voriconazole is a broad-spectrum azole exhibiting strong anti-Aspergillus activity and good long-term tolerance. However, the evidence for voriconazole efficacy against refractory Aspergillus otomycosis is weak.

Method:

We reviewed the medical records of patients with Aspergillus otomycosis treated with voriconazole from January 2008 to June 2012 in a Taiwanese regional hospital. Demographic data and information regarding underlying diseases, clinical features, treatment and outcome were assessed.

Results:

In total, 14 cases of Aspergillus otomycosis were treated with voriconazole, including 5 patients with Aspergillus invasive otitis externa. All patients had failed to respond to local treatment, antibiotics or topical agents. One case was lost to follow up. The symptoms of two patients recurred after voriconazole treatment: one patient received a second 12-week course of voriconazole and was cured; and symptoms of the other patient recurred after a second 12-week course of voriconazole, leading to surgical debridement. The remaining 11 patients were cured by voriconazole treatment without extensive surgical debridement.

Conclusion:

This study demonstrates that voriconazole can be a very effective and convenient therapeutic option for the management of refractory Aspergillus otomycosis.

Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome

BACKGROUND

The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.

METHODS

Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.

RESULTS

Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).

CONCLUSIONS

Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.

Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Background:

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

Case report:

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Conclusion:

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

Are systemic voriconazole and caspofungin ototoxic? An experimental study with rats

Objectives

To determine whether systemic administration of voriconazole and caspofungin causes ototoxicity.

Methods

This study was conducted on 32 healthy male Wistar albino rats. The baseline auditory brainstem response (ABR) thresholds of all animals were obtained under general anesthesia. Then, the rats were randomly divided into 4 groups (groups I-IV), each group consisting of 8 rats. Rats in group I were injected intraperitoneally with voriconazole 10 mg/kg/day for 7 days, and the rats in the group II were injected intraperitoneally with caspofungin 5 mg/kg/day for 7 days. Group III received 120 mg/kg/day gentamicin for 7 days. Group IV received saline for 7 days. The animals were then observed for 7 days, and on 14th day of the trial, posttreatment ABRs of both ears were recorded.

Results

We did not find any significant differences between pretreatment and posttreatment median ABR thresholds in the voriconazole, caspofungin, or saline groups. In the gentamicin group, there was a statistically significant difference between pretreatment and posttreatment ABR thresholds.

Conclusion

Caspofungin and voriconazole did not change ABR thresholds in speech frequencies after a 7-day-period of their administration. We believe that further animal studies must be performed after administration of these agents for a longer time period, and these findings must be consolidated with histopathological investigations.

Fungal otomastoiditis: a case series in immunocompetent adults

Fungal otomastoiditis is a rare condition and is usually associated with host immunodeficiency. It is difficult to diagnose, and many cases are fatal. Treatment consists of surgical debridement, attempts to control the underlying immunological condition and antifungal chemotherapy. Individual case reports in immunocompetent patients have been published previously. We report a case series of seven with fungal otomastoiditis, all in immunocompetent patients.