High dose ketoconazole in the treatment of cerebral aspergilloma

Intracranial fungal granuloma

BACKGROUND

Intracranial fungal granulomas are uncommon and their pathogenesis, clinical picture, and effectiveness of therapy remains unclear.

METHODS

Thirty-two cases were studied retrospectively in two groups: (1) Rhinocerebral group (22 cases) had a chronic paranasal sinus (PNS) disease with secondary involvement of skull base, cranial nerves, and/or brain. The granulomas were adherent to dura, firm, avascular, and tough, requiring a knife to cut. (2) Primary intracranial group (10 cases) had no detectable PNS lesion at initial presentation. The granulomas were soft, suckable, and contained pus or necrotic material.

RESULTS

Postoperative and overall mortality were 37.5% and 50%, respectively. Meningoencephalitis was the most common cause of death. Altered sensorium, pus in the granuloma, and/or severe brain edema were poor prognostic factors. All survivors except four have symptomatic residual or recurrent lesions.

CONCLUSION

Early diagnosis with MRI or stereotactic biopsy, radical surgery, and high dose and chronic suppressive chemotherapy may improve overall results in these cases.

Syndrome of the anterior spinal artery as the primary manifestation of aspergillosis

Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. Beside cerebral involvement spinal cord lesions are extremely rare. To our knowledge, aspergillosis initially presenting with acute paraplegia due to mycotic thrombosis of the anterior spinal artery in a formerly healthy patient has, so far, not been reported. Neither a primary focus nor an underlying disease had been detected.

Invasive central nervous system aspergillosis: cure with liposomal amphotericin B, itraconazole, and radical surgery--case report and review of the literature

Invasive aspergillosis of the central nervous system is a rare but well-described disease. There have been only a few reported survivors, and mortality exceeds 95% in the immunosuppressed host. We present a 2-year-old boy with acute lymphatic leukemia and multiple Aspergillus brain abscesses who was successfully treated with liposomal amphotericin B, itraconazole, and surgical excision of the abscesses. Liposomal amphotericin B is a new preparation that safely allows the attainment of significantly higher tissue levels with less toxicity than standard amphotericin B. The treatment of patients with invasive central nervous system aspergillosis is reviewed.

Intracranial aspergillus granuloma

Intracranial aspergillus granulomas over a 12-year period were studied retrospectively. Three distinctive types of presentations were seen, namely nine patients had the rhinocerebral form with primary involvement of the air sinuses and secondary involvement of the skull base, cranial nerves and brain, three patients with the apparently purely intracranial form presented like any other space occupying lesion and one patient who had a 'stroke-like' presentation had a parasellar lesion. None of these patients were immunocompromised. The clinical features, and the medical and surgical options are discussed together with outcome.

Continual intracavitary administration of amphotericin B as an adjunct in the treatment of aspergillus brain abscess: case report and review of the literature

Aspergillus brain abscess is often a fatal disease, regardless of the mode of therapy. Most often seen in the compromised host, it is notoriously refractory to systemic antifungal agents and intrathecal antimycotics. Even with radical surgical debridement, only 13 patients, including the present case, have survived longer than 3 months after being treated for aspergillus brain abscess or granuloma. Studies have shown poor penetration of amphotericin B into the brain and cerebrospinal fluid. One way to achieve therapeutic levels of the agent near the abscess is through the direct introduction of the agent into the abscess site via an indwelling catheter. In the present case, a woman with an aspergillus abscess of the left temporal lobe was treated by a combination of systemic agents, radical debridement, and local therapy, resulting in a cure with a follow-up of 6 years. This is the first reported instance of the use of long-term, local antifungal therapy delivered to the area of the abscess cavity, using a closed reservoir system, and this patient is only the second renal transplant patient reported to have survived aspergillus brain abscess. This form of treatment produced no untoward long-term side effects or neurological sequelae. Local irrigation with antifungal agents should be considered in conjunction with systemic antifungal drugs and drainage and/or debridement in cases of fungal intracerebral aspergilloma. This technique may also prove useful with other fungal brain lesions.

Control of proven pulmonary and suspected CNS aspergillus infection with itraconazole in a patient with chronic granulomatous disease

An 11-year-old boy with chronic granulomatous disease caused by cytochrome b deficiency developed right upper lung lobe aspergillosis. Intracerebral lesions developed on maximum doses of flucytosine and amphotericin B. Treatment with 16 mg/kg oral itraconazole was followed by a dramatic clinical improvement and almost complete disappearance of the intracerebral lesions. Plasma itraconazole levels were between 40 and 3440 ng/ml depending on concomitant medication. Toxicity was restricted to transient elevation of alkaline phosphatase and gamma glutamyl transferase. We conclude that further trials with itraconazole are justified in high risk patients in whom conventional therapy has failed.