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Hong W, Liu Y, Chen M, Lin K, Liao Z, Huang S. Secondary headache due to aspergillus sellar abscess simulating a pituitary neoplasm: case report and review of literature. SPRINGERPLUS 2015; 4:550. [PMID: 26435896 PMCID: PMC4582039 DOI: 10.1186/s40064-015-1343-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/15/2015] [Indexed: 11/10/2022]
Abstract
Fungal sellar abscess is rare. A 42-year-old man was admitted with 2-month headache characterized by right peri-orbital pain. An intrasellar mass was found to be simulated a pituitary neoplasm after magnetic resonance imaging examination, and operated on via an endoscopic trans-sphenoidal approach. Milk-like pus and a mass of ash black mixed and necrotic material were found and removed. Histopathology revealed numerous aspergillus hyphae. Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks. No recurrence was observed during follow-up. Complete surgical resection through endoscopic trans-sphenoidal approach combined with systemic anti-fungal therapy, should be considered as the optimal treatment.
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Affiliation(s)
- Wenyao Hong
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
| | - Yuqing Liu
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
| | - Mingwu Chen
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
| | - Kun Lin
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
| | - Zhengjian Liao
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
| | - Shengyue Huang
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, 134 Dongjie Road, Gulou District, Fuzhou, 350001 China
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Chronic Invasive Sinus Aspergillosis in Immunocompetent Hosts: A Geographic Comparison. Mycopathologia 2010; 170:403-10. [DOI: 10.1007/s11046-010-9338-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 06/11/2010] [Indexed: 11/26/2022]
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Invasive aspergillosis presenting with a painless complete ophthalmoplegia. Clin Neurol Neurosurg 2009; 112:85-7. [PMID: 19910107 DOI: 10.1016/j.clineuro.2009.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 10/09/2009] [Accepted: 10/09/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We report on a patient who presented with complete ophthalmoplegia as a first symptom of fatal invasive aspergillosis. CASE REPORT We present the clinical course of an immunocompromised 68-year-old man with unclear painless loss of vision, ptosis and ophthalmoplegia of the right eye lasting for 10 days which was referred from an ophthalmological outpatient clinic. He had a history of kidney transplantation after renal failure, diabetes mellitus II, and coronary heart disease. He was on immunosuppressive therapy with tacrolimus, mycophenolate and prednisolone since renal transplantation. The initial cranial magnetic resonance imaging (MRI) was unremarkable. The additional thin section computed tomography (CT) of the paranasal sinuses was suspicious for bone erosion of the superior wall of the right sphenoidal sinus. Initial laboratory testing and cerebrospinal fluid were without pathological findings. When the patient showed signs of generalised sepsis he was transferred to the intensive care unit. Due to fulminant sepsis it was not possible to perform the planned biopsy. The patient died a few days later of cardio-respiratory insufficiency. The consecutive autopsy revealed invasive aspergillosis of paranasal sinuses with infiltration into the orbita and intracranial spreading into sinus cavernous. Autopsy also showed aspergillus pneumonia. DISCUSSION Invasive aspergillosis of the paranasal sinuses and the skull base is most often a lethal condition in immunocompromised patients. Therefore, rapid diagnostics applying radiological (CT and MRI) and surgical procedures (biopsy) and immediate ignition of antimycotic treatment can be life-saving.
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Carpinteri R, Patelli I, Casanueva FF, Giustina A. Pituitary tumours: inflammatory and granulomatous expansive lesions of the pituitary. Best Pract Res Clin Endocrinol Metab 2009; 23:639-50. [PMID: 19945028 DOI: 10.1016/j.beem.2009.05.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inflammatory and granulomatous diseases of the pituitary are rare causes of sellar masses. Lymphocytic hypophysitis is the most relevant of these disorders, and it is characterised by autoimmune pathogenesis with focal or diffuse inflammatory infiltration and varying degrees of pituitary gland destruction. Endocrine symptoms may include partial or total hypopituitarism, with adrenocorticotropic hormone (ACTH) deficiency being the earliest and most frequent alteration. Pituitary abscess is a rare but potentially life-threatening disease and, in 30-50% of patients, anterior pituitary hormone deficiencies or central diabetes insipidus (DI) at onset may be observed: the earliest manifestation being growth hormone deficiency (GHD), followed by follicle-stimulating hormone (FSH)/luteinising hormone (LH), thyroid-stimulating hormone (TSH) and ACTH deficiencies. Fungal infections of the pituitary are also very rare and include aspergillosis and coccidioidomycosis. Concerning pituitary involvement in systemic diseases, in sarcoidosis endocrine complications are rare, but the hypothalamus and pituitary are the glands most commonly affected. DI is reported in approximately 25-33 % of all neurosarcoidosis cases and is the most frequently observed endocrine disorder. Hyperprolactinaemia and anterior pituitary deficiencies may also occur. Rarely, partial or global anterior pituitary dysfunction may be present also in Wegener's granulomatosis, either at onset or in the course of the disease, resulting in deficiency of one or more of the pituitary axes. Other forms of granulomatous pituitary lesions include idiopathic giant cell granulomatous hypophysitis, Takayasu's disease, Cogan's syndrome and Crohn's disease. The hypotalamic-pituitary system is involved mainly in children with Langerhans' cells histiocytosis who develop DI, which is the most common endocrine manifestation. Anterior pituitary dysfunction is found more rarely and is almost invariably associated with DI. Pituitary involvement may also be observed in another form of systemic hystiocitosis, that is, Erdheim-Chester disease. Tuberculosis is a rare cause of hypophysitis, which may present with features of anterior pituitary dysfunction, such as hypopituitarism with hyperprolactinaemia. In conclusion, in patients with a sellar mass and unusual clinical presentation (DI, neurological symptoms), aggressiveness and onset and in the presence of systemic diseases, inflammatory and granulomatous pituitary lesions should be carefully considered in differential diagnosis.
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Affiliation(s)
- R Carpinteri
- Department of Medical and Surgical Sciences, University of Brescia, Endocrine Service, Montichiari Hospital, via Ciotti 154, 25018 Montichiari, Italy
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Lee TJ, Huang SF, Chang PH. Characteristics of Isolated Sphenoid Sinus Aspergilloma: Report of Twelve Cases and Literature Review. Ann Otol Rhinol Laryngol 2009; 118:211-7. [DOI: 10.1177/000348940911800309] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Isolated sphenoid sinus aspergilloma (ISSA) is a form of fungal sinus infection that is distinct from allergic fungal sinusitis, invasive fungal disease, and Aspergillus granulomas. In this study, we identify the characteristics of patients with ISSA to achieve timelier intervention for this easily neglected disease. Methods: In a retrospective study of patients with ISSA in our institution (1995 to 2006), 12 were identified. Results: Sixty-seven percent of our patients were more than 50 years of age, and a female preponderance was noted. Headache and postnasal drip were the two most common symptoms, and the samples from 78% of our patients with postnasal drip were blood-tinged. Computed tomographic scanning provided a sensitivity of 64%, whereas endoscopic examination failed to identify abnormalities in any patients. Conclusions: Four characteristics were identified in the diagnosis of ISSA: Female; usually above 50 years of age; with postnasal drip (especially blood-tinged); and headache (particularly periorbital or retro-orbital).
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Makhdoom N, Balkheur K, Foda MA, Fadel MM, Haroon A, Othman H, Al Sheikh S. Fungal Sinusitis with Intracranial Extension in Immuno-competent Patients: Surgical Planning According to Relation to Eloquent Neurovascular Structures. J Taibah Univ Med Sci 2008. [DOI: 10.1016/s1658-3612(08)70042-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Pinzer T, Reiss M, Bourquain H, Krishnan KG, Schackert G. Primary aspergillosis of the sphenoid sinus with pituitary invasion - a rare differential diagnosis of sellar lesions. Acta Neurochir (Wien) 2006; 148:1085-90; discussion 1090. [PMID: 16855812 DOI: 10.1007/s00701-006-0811-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 04/25/2006] [Indexed: 11/27/2022]
Abstract
Aspergillosis belongs to the group of mycotic diseases of paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Isolated aspergillosis of the sphenoid sinus or the clivus is a difficult diagnosis, since the often misleading clinical manifestations of this rare disease develop late. These patients become apparent by neurological signs such as cavernous sinus syndrome, pseudotumor of the pituitary or the orbit. Diagnosis is often made intra-operatively or on histological examination. We report a case of invasive aspergillosis uniquely involving the sellar area revealed by clinical features suggesting a pseudotumor of the pituitary. Although such lesions are almost always seen in immune suppressed subjects, in our case, the patient was immune competent and had no past history of sinusitis.The question of whether, and when to perform limited or extensive surgery remains an issue for discussion, owing to the rarity of this disease honed by lack of experience. It depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.
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Affiliation(s)
- T Pinzer
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Dresden, Dresden, Germany
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Mohindra S, Gupta R, Mohindra S, Gupta SK, Vaiphei K. Cerebellar Aspergillosis in an Infant: Case Report. Neurosurgery 2006; 58:E587; discussion E587. [PMID: 16528155 DOI: 10.1227/01.neu.0000197485.40244.a8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
Intracranial aspergillosis is occasionally seen among immunocompromised patients, the incidence increasing in consequence to large-scale use of chemotherapy against malignancies and immunosuppression after organ transplantation. Immunocompetent patients harboring invasive intracranial fungal infections still remain an elusive diagnosis.
CLINICAL PRESENTATION:
A 7-month-old immunocompetent infant who developed and harbored cerebellar aspergillosis until 3 years of age is reported.
INTERVENTION:
Radical surgical resection of posterior fossa mass (aspergilloma) and parenteral administration of Amphotericin B led to a successful outcome.
CONCLUSION:
The differential diagnosis at both stages of presentation and the possible mode of infection are discussed according to the radiological images. Preoperative diagnosis on the basis of imaging is difficult. The pathogenesis of such an infection remains uncertain. Parenteral Amphotericin B, followed by prolonged itraconazole therapy, remains the “gold standard” modality for central nervous system fungal infections in adjunct to aggressive surgical debridement.
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Affiliation(s)
- Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Siddiqui AA, Shah AA, Bashir SH. Craniocerebral Aspergillosis of Sinonasal Origin in Immunocompetent Patients: Clinical Spectrum and Outcome in 25 Cases. Neurosurgery 2004; 55:602-11; discussion 611-3. [PMID: 15335427 DOI: 10.1227/01.neu.0000134597.94269.48] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2003] [Accepted: 05/06/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Craniocerebral aspergillosis of sinonasal origin has been reported mainly in immunocompromised patients with high mortality, and it has been described very infrequently in immunocompetent hosts. This retrospective study focuses on clinical outcome in relation to anatomic locations of invasive aspergillosis of sinonasal origin in immunocompetent patients with emphasis on our preliminary experience with use of preoperative orally administered itraconazole.
METHODS:
Medical records of patients treated in two tertiary care hospitals from 1991 to 2003 were reviewed retrospectively. All patients had radiological evidence of disease in the paranasal sinuses with or without intracranial extension. The study cohort was divided into three types on the basis of area of involvement revealed by computed tomographic or magnetic resonance imaging scans of brain. All patients underwent surgical intervention and treatment with antifungal therapy. Preoperative orally administered itraconazole therapy was used in four patients on the basis of neuroradiological features. Clinical outcome was assessed with the Glasgow Outcome Scale, and univariate analysis of prognostic factors was performed with 95% confidence interval (P = 0.05).
RESULTS:
Mean patient age was 36.5 years (range, 14–74 yr) with a male preponderance (male-to-female ratio, 23:2). Nasal stuffiness (n = 13), headaches (n = 10), proptosis (n = 9), and nasal discharges (n = 7) were major presenting clinical features. Radiological data were obtained by computed tomographic (n = 25) and magnetic resonance imaging (n = 20) scans of the brain, and diagnoses were established by histopathological analysis (n = 20) or/and fungal cultures (n = 15). Preoperative orally administered itraconazole was given in four patients with intracerebral aspergillosis. Overall mortality was 28% and was highest in patients with Type 1 aspergillosis (66.7%). Type 3 aspergillosis and use of preoperative itraconazole remained statistically significant prognostic factors.
CONCLUSION:
Craniocerebral aspergillosis in immunocompetent hosts has three patterns of presentation that seem to correlate with clinical outcomes. Intracerebral aspergillosis (Type 1) is associated with the worst clinical outcome. Patients with orbital and cranial base aspergillosis (Type 3) had good recovery. Intracranial extradural aspergillosis (Type 2) remained intermediate on the Glasgow Outcome Scale. Preoperative orally administered itraconazole therapy may improve clinical outcome in patients with intracerebral aspergillosis. Prospective clinical studies are required to make firm clinical therapeutic recommendations.
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Petrick M, Honegger J, Daschner F, Feuerhake F, Zentner J. Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature. Neurosurgery 2003; 52:955-8; discussion 958-9. [PMID: 12657193 DOI: 10.1227/01.neu.0000053026.02658.4b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2002] [Accepted: 11/11/2002] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Isolated fungal granulomas originating within the sphenoid sinus are extremely rare in immunocompetent patients. In their symptoms and morphological appearance, these lesions may be mistaken for pituitary tumors. We report such a case and review the literature. CLINICAL PRESENTATION A 74-year-old man presented with a 3-week history of Cranial Nerve III paresis. The patient had a long-term history of snuff abuse. Computed tomography demonstrated a space-occupying lesion of the sellar and sphenoid sinus region with displacement of the cavernous sinus. INTERVENTION The lesion was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, mucus extruded spontaneously, and a brownish, crumbly mass was found and removed. The lesion had completely eroded the sella and clivus. Histological analysis revealed numerous Aspergillus hyphae. Postoperatively, the IIIrd cranial nerve paresis resolved completely within a few days. No systemic fungal infection was found in extensive serological studies. There was no evidence of immunosuppression. CONCLUSION Fungal granuloma must be included in the differential diagnosis of lesions in the sellar region, even in nonimmunosuppressed patients. Early diagnosis and transsphenoidal extirpation is crucial with this potentially life-threatening disease.
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Affiliation(s)
- Manfred Petrick
- Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany.
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Tzen KY, Yen TC, Lin KJ. Value of Ga-67 SPECT in monitoring the effects of therapy in invasive aspergillosis of the sphenoid sinus. Clin Nucl Med 1999; 24:938-41. [PMID: 10595472 DOI: 10.1097/00003072-199912000-00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- K Y Tzen
- Department of Nuclear Medicine, Chang Gung Memorial Hospital, Taipei Medical Center and School of Medicine, Chang Gung University, Taiwan.
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