Sino-orbital-cerebral aspergillosis in immunocompromised pediatric patients

Aspergillus terreus panophthalmitis with orbital cellulitis

An eleven year old male reported a ten-day history of unilateral pain, redness, and sudden loss of vision. Ophthalmic examination revealed panophthalmitis that did not respond to conventional intravenous antibiotics, and systemic deterioration raised suspicion of a fungal aetiology. However, the worsening of the ocular condition from panophthalmitis to orbital cellulitis upon commencement of amphotericin B suggests the presence of a fastidious microorganism. Aspergillus terreus was isolated from a vitreous tap sample and responded well to intravenous voriconazole, exhibiting a distinct antimicrobial susceptibility spectrum and emphasising its possible involvement in relatively healthy early adolescence. To the author's knowledge, panophthalmitis with orbital cellulitis in early adolescence, without prior ocular insult, paranasal sinus involvement, or immunocompromised status, has not been reported previously.

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.

Fungal Infections of the Central Nervous System in Children

Although uncommon in children, fungal infections of the central nervous system can be devastating and difficult to treat. A better understanding of basic mycologic, immunologic, and pharmacologic processes has led to important advances in the diagnosis and management of these diseases, but their mortality rates remain unacceptably high. In this focused review, we examine the epidemiology and clinical features of the most common fungal pathogens of the central nervous system in children and explore recent advances in diagnosis and antifungal therapy.

Diagnostic Imaging and Invasive Fungal Diseases in Children

Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.

Invasive aspergillosis in a patient with end stage renal disease

Invasive aspergillosis caused by A. Fumigatus, almost occurs in immunocompromised hosts and has a poor prognosis. We report a case of invasive Aspergillosis in a 15-year-old boy with ESRD. He was initially diagnosed as lobar pneumonia and peritonitis. When he complained for lower extremity weakness and had convulsions, a solid mass originated from right lung compresses the spinal cord and intracranial hemorrhagic abscesses were found on MRI. The biopsy specimen showed hypae of aspergillus-spp and he died on 12th day.

Acute Rhinosinusitis in Immunosuppressed Children: Diagnostic and Therapeutic Management

BACKGROUND

Immunosuppressive therapy places pediatric patients at risk of developing life-threatening sinonasal infections. Diagnosis and treatment are challenging owing to nonspecific signs and symptoms. The aim of this study was to present our department's experience with the surgical management of acute rhinosinusitis in immunosuppressed children.

METHODS

The records of all children with a hematologic or oncologic disease who underwent endoscopic sinus surgery (ESS) for acute rhinosinusitis from January 2005 to May 2014 were reviewed. Data were retrospectively collected on demographics, clinical and imaging characteristics, microbiology, pathology, treatment and outcome.

RESULTS

Thirty-four-immunosuppressed children underwent ESS for acute rhinosinusitis. Most patients had a fungal infection. Nineteen patients died at the end of follow-up; 10 deaths were infection-related. Facial swelling was the only symptom that correlated with death of infection. Relapse of the underlying disease, bone marrow transplantation, and long duration of neutropenia correlated with infection-related mortality. Fungal infection, and specifically Aspergillus, correlated with death from infection.

CONCLUSIONS

ESS is a safe and efficient procedure for diagnosing and treating immunosuppressed pediatric patients with acute rhinosinusitis. Early detection and aggressive medical and surgical treatment, with control of underlying risk factors, are crucial to improve outcome.

Invasive Aspergillus Sinusitis in Human Immunodeficiency Virus Infection: Case Report and Review of the Literature

Invasive Aspergillus (IA) sinusitis is a life-threatening opportunistic infection in immunocompromised individuals, but it is uncommon in human immunodeficiency virus (HIV) infection. To gain a better understanding of the characteristics of IA sinusitis in this population, we present a unique case of chronic IA sinusitis in an HIV-infected patient taking antiretroviral therapy and review the literature summarizing published cases of invasive aspergillosis of the paranasal (n = 41) and mastoid (n = 17) sinuses in HIV-infected individuals. Among these cases, only 4 were reported after 1999, and 98% of patients had acquired immune deficiency syndrome. Orbital invasion occurred in 54% of paranasal sinus cases, whereas intracranial invasion was reported in 53% of mastoid sinus cases. The overall mortality was 79%. We also discuss various clinical and immunologic factors that may play a role in the development of IA and consider the changing epidemiology of aspergillosis in the era of effective antiretroviral therapy.

Ocular manifestations of idiopathic aplastic anemia: retrospective study and literature review

Aplastic anemia (AA) is a rare disease with few reports on its ophthalmic manifestations. The ocular findings are described in a retrospective consecutive series of 719 AA Korean patients followed at the Hematology Clinic of The Catholic University of Korea. Out of a total of 719 patients, 269 patients had eye examinations, 156 patients had retinal evaluation, and 37 (23.7%) had retinal findings. These 37 patients had unilateral retinal hemorrhage in seven and bilateral retinal hemorrhage in 30 with mean hemoglobin of 6.6 g/dL (range 2.7–12.6 g/dL) and platelet counts of 18.8×10⁹/L (range 4–157×10⁹/L); central retinal vein occlusion-like picture occurred in nine patients and these had similar rheology to the rest of the subjects; optic disc edema, cotton-wool spots, macular edema, and dry eyes occurred in two, three, five, and three patients, respectively. In this Korean series of 141 subjects with AA, systemic bleeding occurred in 24.8% of subjects, retinal hemorrhage in 37% of subjects, and any bleeding site (eye or elsewhere) occurred in 47.5% of subjects with AA. A literature review (1958–2010) of 200 AA cases revealed retinal hemorrhages in 56%, subhyaloid or vitreous hemorrhage in 9%, peripheral retinal vasculopathy in 5.5%, and cotton-wool spots, Sjögren’s syndrome, or optic disc edema in 4% each. The prevalence of retinopathy among series of AA patients varied from 20% to 28.3%, which is consistent with the Korean series of 24.8%. Management of AA patients needs to involve multiple specialties, including hematologists, ophthalmologists, and infectious disease specialists.

Rhino-Orbital-Cerebral Mycosis and Cavernous Thrombosis

Rhino-orbital-cerebral mycosis (ROCM) is a life-threatening fungal disease associated mostly with Mucoralean fungi. The infection presents as headache, vision loss, proptosis, ptosis, painful ophthalmoplegia, and peripheral face palsy, with a high mortality (>80% for infections that spread to the brain) and severe morbidity, such as eyeball exenteration and vision loss. In our hospital, a 61-year-old woman with diabetes was diagnosed with rhino-orbital-cerebral infection caused by Alternaria infectoria. Cavernous sinus thromboses (CST) were seen in surgery, pathology, and MRI. She did not respond to potent antifungal therapy until the adding of anti-thrombosis drugs. By analyzing our case, together with the ones that have been published, we realized that fungal thrombosis in the cavernous sinus is the main pathophysiological problem in ROCM that typically shows mass enhancement within the cavernous sinus in radiographic images, thrombosis with characteristics of ischemia and infarction in pathology. Anticoagulation/antithrombus therapy might be helpful in the management of ROCM if potent antifungal treatment does not have effect.

Galactomannan antigenemia in pediatric oncology patients with invasive aspergillosis

BACKGROUND

Diagnosing invasive aspergillosis is difficult but might be improved by detection of circulating galactomannan. Although galactomannan antigenemia has been well studied in the detection of invasive aspergillosis in adult patients, little is known about the expression of circulating galactomannan in immunocompromised children with invasive aspergillosis.

METHODS

We studied the expression of galactomannan antigen by enzyme immunoassay (EIA) in 990 serum samples from 56 pediatric oncology patients (ages 3 months to 18 years) of whom 17 had proven or probable invasive aspergillosis defined by the European Organization for Research and Treatment of Cancer-Mycoses Study Group criteria. Any sample with a galactomannan EIA Galactomannan index value of > or = 0.5 was considered positive.

RESULTS

At least 1 serum sample was positive for 11 of 17 pediatric oncology patients (65.7% sensitivity, 95% confidence interval: 38.3-85.7) with invasive aspergillosis. Galactomannan EIA was positive in 99 of 304 samples from patients with proven or probable invasive aspergillosis, and 7 of 686 (1.0%) samples from 39 control subjects resulted in a positive galactomannan EIA result. At least 1 sample tested positive in 5 of the 39 controls (12.8%, 95% confidence interval: 4.3-27.4). No significant association between accuracy and patient age was observed. Among the 7 evaluable galactomannan-positive patients with IA, the galactomannan EIA produced a positive result before clinical or radiographic evidence of infection in 6 cases, with a lead-time to diagnosis ranging from 1 day to 34 days (median: 10 days). In the remaining case, a positive galactomannan was observed on the same day as diagnosis by non-EIA methods.

CONCLUSIONS

The presence of circulating galactomannan is predictive of invasive aspergillosis in most pediatric oncology patients. Galactomannan antigenemia may precede clinical, microbiologic, or radiographic evidence of invasive aspergillosis.

Invasive Aspergillus terreus sinusitis with orbitocranial extension: case report

BACKGROUND

Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient.

CASE DESCRIPTION

This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month.

CONCLUSION

A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.

Intracranial aspergillosis in children successfully treated with antifungal therapy and surgical intervention

Invasive aspergillosis is an uncommon but often lethal complication in immunocompromised patients. Despite the progress obtained with new antifungal drugs, intracranial aspergillosis often requires a combined medical and surgical approach. Most cases previously reported in immunocompromised children were fatal. We describe 4 immunosuppressed children with intracranial aspergillosis successfully treated with surgery and antifungal long-term therapy.

Nasolacrimal sac hematoma masquerading as an orbital mass

A distended or infiltrated nasolacrimal sac can present as a mass in the medial orbit. We present a case of aspergillus sinusitis complicated by intractable epistaxis after debridement of the nasal septum, which caused pain and rapid distension of the nasolacrimal sac. The clinical and radiographic appearance of the distended nasolacrimal sac mimicked the appearance of an orbital mass and orbital extension of aspergillosis. After embolization of the maxillary artery to control the epistaxis, the nasolacrimal sac hematoma spontaneously resolved, and the patient proceeded with his medical treatment without the need for orbital surgery.

Resolution of orbitocerebral aspergillosis during combination treatment with voriconazole and amphotericin plus adjunctive cytokine therapy

Orbitocerebral aspergillosis has a very high fatality rate and cure is unusual. We describe the successful management of a child with cereberal aspergillosis who had a dramatic response to therapy with a combination of liposomal amphotericin and voriconazole with adjunctive cytokine therapy during immunosuppresive chemotherapy for acute lymphoblastic leukaemia.

Cerebral aspergillosis in an infant with corticosteroid-resistant nephrotic syndrome

Cerebral aspergillosis is a devastating disease in patients with a compromised immune system. A unique case of a male infant with corticosteroid-resistant nephrotic syndrome complicated by pulmonary and cerebral aspergillosis is described. The patient rapidly developed coma and neurological symptoms and died soon thereafter. Central nervous system aspergillosis was diagnosed radiologically and by detection of Aspergillus DNA and antigen (galactomannan) in blood and cerebrospinal fluid. Moderate immunosuppressive therapy and antifungal phagocytic dysfunction due to nephrotic syndrome per se may have contributed to the occurrence of invasive aspergillosis in our patient. Awareness of this serious complication and early application of diagnostic procedures and antifungal therapy may improve the dismal outcome.