Intracranial Aspergillus infection from the paranasal sinus

Impact of Surgical and Medical Treatment on Survival of Patients with Cerebral Aspergillosis: Systematic Review of the Literature

OBJECTIVE

Cerebral aspergillosis carries a high mortality. Rapid diagnosis and treatment can increase survival, but symptoms and imaging findings are nonspecific. The literature on cerebral aspergillosis consists mostly of case reports and case series and lacks large-scale review of data.

METHODS

We performed a review of the literature using PubMed in March 2019. We recorded the year of publication, age and sex of patients, neurosurgical involvement, the antifungals administered, use of intrathecal antifungals, and the outcome of patients. The relationships among variables were tested using bivariant statics and linear regression.

RESULTS

A total of 324 studies met the eligibility criteria, and 198 studies including 248 patients were included. Surgical resection (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.25-0.80; P < 0.01) and administration of voriconazole (OR, 0.32; 95% CI, 0.18-0.55; P < 0.001) or itraconazole (OR, 0.36; 95% CI, 0.16-0.72; P < 0.001) were shown to be significantly associated with survival.

CONCLUSIONS

Given the significant survival benefits for patients who received voriconazole and surgical intervention, we suggest early antifungal medical treatment and resection.

Skull base tumors: a kaleidoscope of challenge

Resection of skull base lesions has always been riddled with problems like inadequate access, proximity to major vessels, dural tears, cranial nerve damage, and infection. Understanding the modular concept of the facial skeleton has led to the development of transfacial swing osteotomies that facilitates resection in a difficult area with minimal morbidity and excellent cosmetic results. In spite of the current trend toward endonasal endoscopic management of skull base tumors, our series presents nine cases of diverse extensive skull base lesions, 33% of which were recurrent. These cases were approached through different transfacial swing osteotomies through the mandible, a midfacial swing, or a zygomaticotemporal osteotomy as dictated by the three-dimensional spatial location of the lesion, and its extent and proximity to vital structures. Access osteotomies ensured complete removal and good results through the most direct and safe route and good vascular control. This reiterated the fact that transfacial approaches still hold a special place in the management of extensive skull base lesions.

Central nervous system aspergillosis: a series of 14 cases from a general hospital and review of 123 cases from the literature

Central nervous system (CNS) aspergillosis is a highly fatal infection. We review the clinical presentation, diagnosis, and outcome of this infection and present a case series of 14 consecutive patients with CNS aspergillosis admitted to Massachusetts General Hospital (MGH) from 2000 to 2011. We also review 123 cases reported in the literature during that time. We included only proven CNS aspergillosis cases conforming to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal infections. In the MGH case series, neutropenia, hematologic malignancies, autoimmune diseases requiring steroid treatment, and solid organ transplantation were the predominant comorbid conditions. Notably, all MGH patients were immunosuppressed, and more than half (n = 8) had a history of previous brain injury, unrelated to their index hospitalization. For most MGH patients (11 of 14), the lung was the primary focus of aspergillosis, while 2 had paranasal sinus involvement, and 1 had primary Aspergillus discitis. Among reported cases, paranasal sinuses (27.6%) and the lung (26.8%) were the primary foci of infection, whereas 22% of those cases had no obvious primary organ involvement. Although a selection bias should be considered, especially among published cases, our findings suggest that patients who underwent neurosurgery had improved survival, with MGH and literature patients having 25% and 28.6% mortality, respectively, compared to 100% and 60.4%, respectively, among patients who received only medical treatment. Although this was not the case among MGH patients, CNS aspergillosis can affect patients without significant immune suppression, as indicated by the high number of reported immunocompetent cases. In conclusion, mortality among CNS aspergillosis patients remains high, and the infection may be more common among patients with previous brain pathology. When indicated, neurosurgical procedures may improve prognosis.

Invasive aspergillosis in an immunocompetent host

Aspergillosis is a common opportunistic fungal infection affecting the nose and paranasal sinuses. The disease presents in various forms ranging from non-invasive to invasive, destructive and allergic types. We report here a rare case of invasive aspergillosis in an immunocompetent host with the literature review.

[Invasive aspergillosis of the maxillary sinus in an immunocompetent patient]

INTRODUCTION

Invasive aspergillosis of the maxillary sinus is a severe infection most commonly observed in immunocompromised patients. We report a pseudo-tumoral presentation of invasive aspergillosis of the maxillary sinus, in immunocompetent adult.

CASE REPORT

A 70-year-old female patient consulted for chronic rhino-sinusitis resistant to medical treatment. Computed tomography scan revealed a hyperdense mass filling the left maxillary antrum, with erosion of sinus walls. The ethmoidal and right frontal sinuses were involved. The histological and mycological examination of the surgical resection confirmed the diagnosis of invasive aspergillosis. The patient was given voriconazole as first line treatment. The outcome was good at 18 months.

DISCUSSION

Invasive aspergillosis of the maxillary sinus is a rare disease, usually observed in immunodepressed patients. It is very rarely observed in immunocompetent patients.

Neuroaspergillosis in an immunocompetent patient successfully treated with voriconazole and a corticosteroid

Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. We report a case of nasocerebral aspergillosis in an immunocompetent patient successfully treated with voriconazole and a corticosteroid. Magnetic resonance imaging (MRI) showed contrast enhancement surrounding the brainstem and cerebellum with intramedullary pontine and cerebellar T2-hyperintense lesions. The patient's symptoms and MRI abnormalities improved after voriconazole and corticosteroid treatment; however, discontinuation of the corticosteroid caused a worsening of the T2-hyperintense lesions, whereas resuming it resulted in its improvement. This suggested that these T2-hyperintense lesions may be due to secondary inflammation caused by aspergillosis and not the aspergillosis itself. We conclude that treatment with a combination of voriconazole and a corticosteroid appears to be effective for the treatment of some patients with CNS aspergillosis.

Combined mucormycosis and aspergillosis of the oro-sinonasal region in a patient affected by Castleman disease

One case of aspergillosis and mucormycosis occurring in a patient with stage-IV Castleman disease was investigated. The patient, who had undergone polychemotherapy and was in otherwise good general condition, without lymphadenopathies or imbalance of the immune system, presented with a palatal ulceration that progressively involved the palatal mucosa and bone, the paranasal sinuses and the orbit. Repeated cultural examinations were always negative. He had undergone multiple cytological smears of the inflammatory infiltration and biopsies of both the oral and nasal mucosa, which resulted in extensive necrotic debris and suppurative inflammation, and, on the very last biopsy, fungal hyphae, spores and conidia were also detected. These were large, branching, mostly non-septate hyphae, associated with conidiophores and conidia, the latter appearing dark brown to black in the histological preparations. Following the diagnosis of combined mucormycosis and aspergillosis, the patient underwent prolonged topic and systemic antibiotic treatment that resulted curative. Mucormycosis usually is a fatal complication of head and neck or systemic disorders, leading to severe immune suppression. Nevertheless, early diagnosis may be achieved using a combination of special stains and may lead to effective antibiotic treatment and cure of the patient, even if associated with other opportunistic infections, such as aspergillosis.