Invasive Orbital Apex Aspergillosis with Mycotic Aneurysm Formation and Subarachnoid Hemorrhage in Immunocompetent Patients

[Micotic aneurysm of the internal carotid artery in a patient with sarcoidosis as a cause of ischemic stroke and profuse epitaxis]

The article describes the following case: a 63-year-old patient with sarcoidosis, who was on long-term therapy with metipred, developed profuse epistaxis, and upon admission to the hospital, clinical manifestation of stroke. Computer tomography (CT) of the brain at admission revealed destruction of the posterior wall of the sphenoid bone and an area of increased density in the projection of the left optic nerve regarded as a neoplasm of the sphenoid sinus or inflammatory changes. CT angiography revealed the occlusion of the left internal carotid artery (LICA) from the C1 segment throughout. At the time of thrombus extraction, the patient developed profuse bleeding from the nasal cavity. According to staged angiography, the antegrade blood flow through the LICA to the sphenoid segment was restored; against the background of profuse bleeding, the flow of contrast from the LICA into the sphenoid sinus and further into the nasopharynx is visualized; in the projection of the sphenoid sinus, a formation was revealed that required differentiation between a giant aneurysm, an arteriovenous fistula, and a neoplasm of the sphenoid sinus. Destructive embolization of the LICA at the level of the petrosal segment was performed for vital indications, the bleeding was stopped, but the patient died due to acute posthemorrhagic anemia. An autopsy revealed a mycotic aneurysm of the LICA, the rupture of the wall of which caused nasal bleeding, which was spontaneously stopped due to the formation of an extended thrombus, which, in turn, became the cause of stroke.

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.

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review

Background:

Central nervous system (CNS) aspergillosis is more often met in patients with expressed immune suppression. Still, in 50% of cases of meningitis caused by Aspergillus spp., it is observed in patients without expressed immune suppression. The prognosis of CNS aspergillosis is unfavorable with the general rate of lethality around 70%.

Case Description:

Clinical case of a 58-year-old man who developed an Aspergillus abscess in the chiasmosellar region and an associated mycotic aneurysm of the right middle cerebral artery (MCA) and intracerebral hemorrhage. Microsurgical clipping of the fusiform-ectatic aneurysm of the right MCA in the conditions of rupture was performed. An extra-intracranial micro anastomosis was formed on the right. An open biopsy of the neoplasm in the chiasmosellar region was made. The neoplasm was yellow and destroyed the bone plate of the skull base. Biopsy results: Mycotic lesion (aspergillosis). The analysis of surgical treatment for mycotic aneurysms in the acute period of hemorrhage in patients with aspergillosis revealed a high rate of lethality. The issue of the feasibility and effectiveness of complicated revascularization interventions in the patients with hemorrhage and aspergillosis remains unsolved.

Conclusion:

The lack of generally accepted tactics of the treatment of this pathology requires further studies and systemic analysis. A high risk of the lethal outcome in patients with invasive mycotic infection and rupture of mycotic aneurysm highlight the importance of timely diagnostics and the beginning of antimycotic therapy. WThe issue of the evaluation of the revascularization methods effectiveness in patients after surgical treatment of a mycotic aneurysm associated with cerebral aspergillosis remains poor.

Invasive aspergillosis of the skull base in an immunocompetent patient: a diagnostic challenge

We describe the case of a 32-year-old man from Cape Verde having headache and increasing visual loss. Clinical and radiological investigations disclosed a massive destructive lesion involving the anterior and central skull base, orbit and nasoethmoid region initially interpreted as a malignant small round cell tumour. Surgical biopsies were negative for neoplasm, showing an intense inflammatory infiltrate together with fungus, later characterised as Aspergillus flavus spp. The patient was immunocompetent with no evidence of congenital or acquired immunodeficiencies. Invasive fungal infections in immunocompetent patients are rare and can be a diagnostic challenge. The best diagnostic clues include the patient's origin from tropical climates, imaging features and the identification of fungal hyphae on pathology specimens. Although a devastating disease in immunocompromised patients, craniocerebral aspergillosis in immunocompetent patients carries a better prognosis. Available literature supports the combined used of 'conservative' surgical resection and antifungal therapy as the best treatment option.

Invasive fungal disease misdiagnosed as tumour in association with orbital apex syndrome

Invasive sino-orbital aspergillosis is a rare cause of orbital apex syndrome (OAS) in immunocompetent patients and often misdiagnosed as tumour because of its aggressive nature and invasive patterns. We report a 23-year-old immunocompetent man presenting with painful progressive loss of vision, ophthalmoplegia and proptosis of the right eye suggestive of OAS. MRI with gadolinium contrast showed an enhancing heterogeneous mass filling the paranasal sinuses, extraconal space and extending up to the right orbital apex. A functional endoscopic biopsy reported as invasive sino-orbital aspergillosis. He was started on intravenous voriconazole and maximal surgical debridement was done. He gradually regained his vision to 20/30 in the right eye. A review of literature reported several such cases which were managed medically or surgically but with poor visual recovery. This case highlights the need for awareness among clinicians for early diagnosis and treatment to prevent vision loss and better survival.

Marine Bioactive Compounds against Aspergillus fumigatus: Challenges and Future Prospects

With the mortality rate of invasive aspergillosis caused by Aspergillus fumigatus reaching almost 100% among some groups of patients, and with the rapidly increasing resistance of A. fumigatus to available antifungal drugs, new antifungal agents have never been more desirable than now. Numerous bioactive compounds were isolated and characterized from marine resources. However, only a few exhibited a potent activity against A. fumigatus when compared to the multitude that did against some other pathogens. Here, we review the marine bioactive compounds that display a bioactivity against A. fumigatus. The challenges hampering the discovery of antifungal agents from this rich habitat are also critically analyzed. Further, we propose strategies that could speed up an efficient discovery and broaden the dimensions of screening in order to obtain promising in vivo antifungal agents with new modes of action.

Invasive fungal infection by Aspergillus flavus in immunocompetent hosts: A case series and literature review

Invasive aspergillosis usually affects immunocompromised hosts with variable manifestations depending on the site of infection. In this article, we present two cases of invasive Aspergillosis in two non-immunocompromised patients; both cases had a paranasal sinuses infection, with intraorbital and intracranial extension, requiring surgery and antifungal treatment with Voriconazole. These cases were initially diagnosed as paranasal sinus neoplasms. However, the pathology and microbiology studies revealed invasive fungal infection by Aspergillus flavus.

Orbital apex syndrome secondary to aspergilloma masquerading as a paranasal sinus tumor: A case report and literature review

RATIONALE

Orbital apex syndrome is a complex clinical disorder featuring a collection of cranial nerve deficits characterized by impairment of the extraocular muscles, the ophthalmic branch of the trigeminal nerve, and even the optic nerve. Sino-orbital aspergillosis is rare but aggressive infection. Surgical resection accompanied by antifungal medication is advised currently.

PATIENT CONCERNS

We report a 61-year-old woman diagnosed as aspergilloma presenting with the characteristic manifestations and imaging features of orbital apex syndrome.

DIAGNOSES

Paranasal sinus tumor was misdiagnosed initially according to magnetic resonance imaging of the orbit. Finally aspergilloma was diagnosed by pathologic report.

INTERVENTIONS

The anti-fungal medication, voriconazole, was administered immediately. Surgical excision was also done due to the poor response to medical treatment.

OUTCOMES

Postoperative follow-up showed no recurrence of aspergillosis but the vision was lost permanently.

LESSONS

Invasive sino-orbital aspergillosis as an aggressive disease with highly invasive patterns and it may be misdiagnosed as tumors. To achieve better prognosis and survival, clinicians should be aware of this distinct manifestation.