Cerebral aspergillosis in immunologically competent patients

Isavuconazole Treatment of Spinal Cord Invasive Aspergillosis Guided by Cerebrospinal Fluid (1,3)-β-d-Glucan Levels in a Patient with Low Interferon-Gamma and Ulcerative Colitis

This case highlights the use of (1,3)-beta-d glucan to direct treatment of a cervical spinal cord Aspergillus fumigatus infection in a 22-year-old woman immunocompromised due to steroid and anti-TNF therapy in the context of ulcerative colitis and interferon gamma deficiency. A 4-year treatment course requiring neurosurgical intervention on four occasions and prolonged antifungal therapy, including isavuconazole, resulted in clinical cure with a corresponding decrease in CSF beta-d-glucan to <30 pg/mL. Serum and CSF galactomannan levels were not elevated at any point during the clinical course.

Brain aspergilloma in an immunocompetent individual: A case report

Background:

Aspergillosis is caused by fungi from the Aspergillus species, mainly Aspergillus fumigatus. Patients with aspergillosis typically have an underlying immunosuppression, and it is rare within the central nervous system (CNS) in an immunocompetent host. The mortality rate is as high as 90% if untreated, and the diagnosis is usually delayed due to nonspecific clinical presentation. This study described a case of CNS aspergillosis in an immunocompetent patient, through which we sought to discuss the current knowledge regarding brain Aspergillus focusing in the immunocompetent host.

Case Description:

A 45-year-old male presented with 2 years of low-intensity headache and history of chronic sinusitis with epistaxis in the left nostril. Fifteen days before admission, he had high-intensity headache, episodes of transient aphasia, and seizure. Imaging showed a contrast-enhancing mass within the left maxillary sinus and another lesion in the left frontal lobe. The left frontal craniotomy was conducted, and complete resection was achieved. Biopsy identified A. fumigatus, and antifungal therapy was initiated. After 2 weeks, a new lesion was detected in the right frontal lobe, and the patient underwent a new procedure with complete lesion resection. Follow-up at 3 weeks did not reveal any evidence of residual or recurrent disease. The patient did not develop neurological complaints and was referred for resection of the remaining lesion by an otolaryngology team.

Conclusion:

Being one of the few cases reporting a successful outcome for brain aspergilloma in an immunocompetent patient after complete surgical resection and amphotericin B and itraconazole therapy, we sought to reveal novel insight into brain aspergillosis.

Cerebral aspergillosis presenting as a space occupying lesion in an immunocompetent individual

Cerebral aspergillosis has the tendency to occur in immunocompromised patients. Less commonly, immunocompetent individuals can be affected, with neuroimaging findings being difficult to interpret. The diagnosis necessitates imaging of the brain as well as the sinuses with biopsy and pathological confirmation. A surgical excision with aggressive antifungal agents are required for a proper management. This case report describes an immunocompetent patient with cerebral aspergillosis that presented radiologically as a suspicious mass to be diagnosed pathologically and excised surgically.

Skull base aspergillosis in an immunocompetent elderly man with early response to steroid

We report the case of a previously well 80-year-old man who presented with subacute bilateral painful optic neuropathy with initial response to corticosteroids but ultimately progressed to a fatal skull base syndrome. Initial presentation of steroid-responsive painful bilateral posterior optic neuropathy, preliminary normal enhanced MRI, normal cerebrospinal fluid and inflammatory markers indicated atypical optic neuritis. However, this progressed to a bilateral orbital apex syndrome with ophthalmoplegia and evidence of abnormal skull base enhancement on subsequent MRI. Biopsy of radiologically abnormal dura was non-diagnostic and negative for fungal stains. He deteriorated and died 8 months after initial presentation. At postmortem, fungal skull base infection was diagnosed. This case demonstrates that chronic skull base fungal infection can: (1) present in elderly immunocompetent patients, (2) show initial improvement with corticosteroids and (3) evade diagnosis on biopsy. We encourage a high index of suspicion for fungal skull base infection in similar cases.

Central nervous system fungal infection in a young male with a history of intravenous drug abuse and hepatitis C

A young male, with a known history of hepatitis C and heroin abuse, was admitted to the emergency department with altered sensorium, left-sided weakness, and no meningeal signs. Initial computed tomography imaging showed hypodensity involving right basal ganglia with mass effect but no hemorrhage. Magnetic resonance imaging revealed multiple nonenhancing small foci of restricted diffusion involving the right basal ganglia, T2 and FLAIR hyperintensity within the right basal ganglia, and internal capsule with mild surrounding edema. The patient was treated for encephalitis and atypical stroke given the history of intravenous drug abuse. Follow-up imaging showed worsening of the brain lesions, with involvement of the contralateral basal ganglia with necrosis and peripheral enhancement. Brain biopsy was ultimately performed and suggested infection with Aspergillus species and associated parenchymal infarction. The patient was treated with voriconazole with subsequent significant clinical improvement.

Central nervous system aspergillosis in an immunocompetent patient: Cure in a hospice setting with very high-dose itraconazole

Aspergillosis of the central nervous system (CNS) is a rare condition with exceedingly high mortality. This study describes the case of an immunocompetent 42-year-old man with a history of intravenous drug use and hepatitis C who developed multiple Aspergillus lesions in the cerebellum. Despite neurosurgery and antifungal therapy with amphotericin B, he had a protracted hospital course with multiple complications, eventually developing cognitive and motor impairment due to progressive cerebellar lesions. After transfer to hospice and palliative care service, oral itraconazole was escalated to 1600 mg/day with the hope of palliating headache, nausea, and cognitive impairment. Remarkably, the patient stabilized and improved over time. After 14 months, this unprecedented high-dose regimen was discontinued, and the patient was discharged home with only mild cerebellar motor impairment.

Adrenal and hepatic aspergillosis in an immunocompetent patient

Invasive aspergillosis, an infection most frequently induced by Aspergillus fumigatus and Aspergillus flavus, typically occurs in immunocompromised patients and is usually transmitted through inhalation of Aspergillus spores. As the lungs are by far the most common site involved in invasive aspergillosis and invasive aspergillosis in immunocompetent hosts is very rare, there have been a few case reports of extra-pulmonary, disseminated invasive aspergillosis in immunocompetent persons. Herein, we report a case of an adult, male, immunocompetent patient with disseminated invasive aspergillosis that successively spread from the right adrenal gland to the left hepatic lobe. The patient was successfully treated through surgical excisions of his adrenal and hepatic masses followed by voriconazole therapy. To our knowledge, this is the first case report of invasive aspergillosis affecting the adrenal glands.

A single aspergillus fumigatus intracranial abscess in an immunocompetent patient with parietal lobe tumorectomy

Aspergillosis of the central nervous system is a rare fungal infection that is mainly reported in patients with immune deficiency, such as AIDS patients and organ transplant patients treated with immunosuppressive agents, and is uncommon among patients with intact immune function. We report here a rare case of intracranial aspergillosis in a patient who had previously undergone a parietal lobe tumorectomy. Aspergillus fumigatus was confirmed by histopathology, and susceptibility tests reported that this infection should respond to voriconazole. We believe the immunosuppression resulting from surgical trauma and glucocorticosteroid treatment may be contributing to the infection, and therefore management of these two factors may improve the 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.

Aspergillosis in the 'nonimmunocompromised' host

Invasive aspergillosis has been classically associated with certain risk factors: cytotoxic chemotherapy, prolonged neutropenia, corticosteroids, transplantation, AIDS. However, the literature is growing that this mycosis, particularly pulmonary aspergillosis, can be seen in patients lacking these factors. Many of the latter patients are in the intensive care unit. Other associated conditions include influenza, nonfungal pneumonia, chronic obstructive lung disease, immaturity, sepsis, liver failure, alcoholism, chronic granulomatous disease and surgery. Certain focal sites, such as sinusitis or cerebral aspergillosis, have additional risk factors. This emphasizes the potential importance of a positive culture for Aspergillus in the critically ill, the need for awareness about possible aspergillosis in patients lacking the classical risk factors, and readiness to proceed with appropriate diagnostic maneuvers.

Multiple Aspergillus cerebellar abscesses in a middle-aged female: case report and literature review

Aspergillus abscesses in the cerebellum are extremely rare, and most cases are solitary. Here, we report the first case of multiple Aspergillus cerebellar abscesses in a 46-year-old female after one mastoidectomy, two craniectomies, and extended use of antibiotics. The possible pathogenesis of this unusual event is discussed. Good outcome was achieved by treatment with a combination of neurosurgical resection and voriconazole (VRC) administration, which we suggest is a potential management plan.

Fatal Aspergillus brain abscess in immunocompetent patient

Intracranial aspergillosis is a rare pathologic condition, difficult to treat and often fatal which generally affects immunocompromised hosts. High-dose steroid therapy represents a risk factor for opportunistic infections. We report a case of fatal brain abscess in an immunocompetent patient with a previous diagnosis of acute disseminated encephalomyelitis (ADEM) in whom a high-dose steroid course has probably contributed to the development of the fungal infection. Despite steroids' relative safety, clinicians must remain alert to potential fatal complication that could arise from their use.

Cerebral aspergillosis: tissue penetration is the key

Cerebral aspergillosis is increasingly recognized in severely immunocompromised patients and, until recently, this type of fungal infection was associated with a mortality approaching 100%. The central nervous system is a protected environment and penetration of drugs across the blood-brain barrier is mainly limited by their molecular size and physicochemical properties, as well as drug interaction with transporter systems (e.g., P-glycoprotein) at the blood-brain barrier. Most antifungal agents are large molecules (>700 Da), which makes sufficient penetration into the central nervous system unlikely. In fact, the available data indicate low levels of most antifungal agents in cerebrospinal fluid and brain tissue, except for fluconazole and voriconazole. Concentrations of voriconazole exceeding inhibitory concentrations for Aspergillus species were found repeatedly in cerebrospinal fluid and brain tissue, including brain abscess material. A recent retrospective study confirmed that voriconazole treatment resulted in improved response and survival rates in patients with cerebral aspergillosis. Data from animal models, which explored escalated doses or combinations of antifungal agents in experimental neuroaspergillosis, suggest that selected combination or dose-escalated therapies might further improve the still unsatisfactory prognosis in this particular type of Aspergillus infection.

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.

Petrous apex aspergillosis as a long-term complication of cholesterol granuloma

Aspergillus infection of the petrous apex is a rare and devastating condition. To date, only two such cases have been reported, which resulted from direct extension of chronic Aspergillus otitis media. We present a case of petrous apex aspergillosis occurring years after surgical drainage of a petrous apex granuloma cyst. Because of the potential lethal nature of this condition, aggressive surgical therapy should be considered early in this illness and may provide the best chance for survival.

Fatal brain infection caused by Aspergillus glaucus in an immunocompetent patient identified by sequencing of the ribosomal 18S–28S internal transcribed spacer

Cerebral aspergillosis has rarely been reported in immunocompetent patients. We herein describe a unique case of cerebral aspergillosis in a healthy adult that led to his death despite aggressive antifungal therapy. Sequencing of ribosomal 18S-28S internal transcribed spacer identified the organism as Eurotium herbariorum, the teleomorph of Aspergillus glaucus.

Multiple Aspergillus brain abscesses in immuno-competent patient with severe cranio-facial trauma

Aspergillosis of the central nervous system (CNS) is a rare, but well described disease in immuno-competent patients. We present a 65-year-old patient who developed neuro-aspergillosis 10 months after severe cranio-facial trauma (Le Fort III). He was treated successfully with surgery including stereotactic drainage and, with Amphotericin B, Liposomal Amphotericin B, and Itraconazol.

A case of invasive central nervous system aspergillosis treated with micafungin with monitoring of micafungin concentrations in the cerebrospinal fluid

Invasive aspergillosis has an extremely high mortality rate. In Japan, micafungin, an echinocandin drug that has a new mechanism of action as an antifungal agent and has a clinical effect against Aspergillus species, became available in 2002. However, little is known about its penetration into the central nervous system (CNS), or its efficacy for the treatment of invasive CNS aspergillosis. We report a 65-y-old female with diabetes mellitus and CNS aspergillosis who was treated with micafungin. During treatment, micafungin concentrations were measured in the cerebrospinal fluid and plasma. On a dose of 300 mg/d, the ratio of the micafungin concentration in the cerebrospinal fluid to that in plasma was extremely low (0.2%-0.05%); nevertheless, the patient did not have a relapse of invasive CNS aspergillosis after micafungin treatment.

Post-operative aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Intracranial invasive aspergillosis originating in the sphenoid sinus: a successful treatment with high-dose itraconazole in three cases

We report three cases of intracranial aspergillosis originating in the sphenoid sinus in immunocompetent patients. The patients presented with an orbital apex syndrome in that a unilateral loss of vision and cranial nerve III palsy were seen in all cases and a contralateral involvement was also seen in one case. Despite the initial treatment with a conventional dose of itraconazole (ITCZ, 200 mg/day), the neurological deficits failed to improve and the granulomatous inflammation was not suppressed. Therefore, we treated with a combination of a high dose of ITCZ at 500-1000 mg/day (16-24 mg/kg/day) and amphotericin B (AMPH-B) at 0.5 mg/kg/day, in conjunction with a pulse dose of methylprednisolone at 1000 mg/day. Two cases responded favorably in that the ocular movements completely recovered, and their maximum serum concentrations of the hydroxy ITCZ were 7816 ng/ml and 5370 ng/ml. However, the other case worsened, despite ITCZ treatment at 16 mg/kg/day, and the serum concentration of the hydroxy ITCZ was 3863 ng/ml. The surgical decompression of the cavernous sinus via an extradural approach was performed, and the dose of ITCZ was increased to 24 mg/kg/day. The resulting serum concentration of the hydroxy ITCZ was 4753 ng/ml, and the outcome of this case has been favorable. These results suggest that a high blood level of the hydroxy ITCZ (more than 4500 ng/ml) is a prerequisite for the successful treatment of intracranial aspergillosis and that the combination treatment of ITCZ with AMPH-B would be preferred. The concomitant use of steroid and/or surgical decompression should be considered, if the invasiveness is not well-controlled in spite of intensive medical therapy.

Craniocerebral Aspergillosis of Sinonasal Origin in Immunocompetent Patients: Clinical Spectrum and Outcome in 25 Cases

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.

Intracranial aspergillosis in a non-immunocompromised patient treated for muscle-invasive bladder cancer

We report a case of intracerebral Aspergillosis in a patient undergoing radical cystectomy for the treatment of muscle-invasive bladder cancer who did not reveal any deterioration of the immune system. Aspergillus fumigatus is an ubiquitously present, airborne fungus that tends to infect the upper respiratory tract. However, the latter was not observed in the patient presented. Complications in the form of an involvement of the central nervous system are very rarely recognized as a result of an Aspergillus infection and primarily occur in patients who are not immunologically competent. To our knowledge, we present the first case of intracerebral invasive Aspergillosis in an otherwise healthy patient diagnosed with an urological malignancy.

Aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis (IA) in transplant patients. In this report, we describe two patients with polycystic kidney disease, who developed AE with cerebral involvement after renal transplantation. Both patients received intense immunosuppression with methyl prednisolone and mycophenolate mofitil (MMF) because of persistent rejection, which rendered them diabetic and vulnerable to opportunistic infections. Endophthalmitis developed within six months of transplantation and was confirmed by microscopy and culture of the vitreous fluid. Patients were treated with combinations of different anti-fungal agents including liposomal amphotericin B, 5-flucytosine, itraconazole, voriconazole and terbinafine. In an electronic MEDLINE review, we found eight further cases of AE in renal transplant patients between 1959 and September 2002. Based on this review, we identified possible risk factors including CMV infection, diabetes mellitus and treatment for rejection with agents such as methyl prednisolone and MMF. In 70% of cases the histology, microscopy or culture of vitreous fluid confirmed the diagnosis. The outcome of AE in renal transplant patients was poor with 70-100% mortality. The review of reported cases and current practice guidelines suggests that vitrectomy and intravitreal amphoterecin B is the treatment of choice. In addition, new antifungal agents with good CSF and ocular penetration such as voriconalzole should be considered for the treatment of invasive cerebral/ocular aspergillosis.

Free latissimus dorsi flap used in treatment of cerebral aspergillosis: a case report and review of the literature

Cerebral aspergillosis infection is a rare disease in children that carries extremely high morbidity and mortality. Although occurring most commonly in the immunosuppressed patient, cerebral aspergillosis infection has been reported after trauma or neurosurgical procedures. Amphotericin B is the main medical therapy for cerebral aspergillosis. However, surgical treatment is often required for cases of abscess or granuloma formation. Despite aggressive antifungal treatment and surgical intervention, aspergillosis of the central nervous system is often fatal. We present a case report in which a free latissimus dorsi muscle flap was used in conjunction with antifungal medication and surgical debridement to treat intracranial and epidural aspergillosis in a young male following complex craniofacial trauma.

Pulmonary aspergillosis in an immunocompetent patient

SUMMARY

A case of an immunocompetent patient with severe Aspergillus infection and radiographic findings typically described with angioinvasive aspergillosis is presented. When Aspergillus is isolated from the sputum in a patient with normal immunity, invasive aspergillosis should be considered when there are extensive radiographic findings characteristic of invasive fungal disease.

Galactomannan enzyme immunoassay for monitoring systemic infection with Aspergillus fumigatus in mice

Intravenous (i.v.) infection of immunocompetent mice with Aspergillus fumigatus was used to investigate the ability of a commercial galactomannan enzyme-linked immunosorbent assay (ELISA) to monitor the course of organ infection after dissemination. The test detected 100% of the fungemias which occurred for up to 5 days after infection. When blood-cultures became negative but there was a high load of fungi in the parenchymal organs and a positive culture from the brain, the ELISA was again positive in all animals. However, when blood cultures as well as brain cultures were negative and lower amounts of fungi demarcated by immune cells were present in the liver and kidneys which was the case between day 5 and 30 of infection, the test was negative in most of the animals. Therefore, the test was excellent for detection of early i.v. infection with Aspergillus fumigatus but not suited for detection of limited organ infection in immunocompetent mice.

Sinocranial aspergillosis: a form of central nervous system aspergillosis in south India

Of the 21 patients with aspergillosis of central nervous system seen during the years 1990-1997, 16 (76%) had aspergillosis of sino-cranial origin. The occupation in patients with sino-cranial aspergillosis was either agricultural or manual work and predisposing risk factors were present in only two (12.5%) patients. Skull-base syndromes were the presenting features in 13 patients and three patients presented with features of intracranial space-occupying lesion. Paranasal sinus mass lesions were seen in all the 16 patients. Computerized tomography showed intracranial extradural-enhancing mass lesions in the anterior, middle or posterior cranial fossa in nine (68%) patients, intracranial and orbital lesions in four and orbital lesions in three. Well-formed granuloma with dense fibrosis was the histological feature. Survival rates were not good even after surgical and antifungal chemotherapy. Surgical treatment was subradical in our series. The majority of cases of sinocranial aspergillosis are reported from countries with temperate climates and the high incidence in these regions is probably related to constant exposure to the high spore content of pathogenic Aspergillus species in the 'mouldy' work environment.

The Department of Neurosurgery at Seoul National University: past, present, and future

The Department of Neurosurgery at Seoul National University College of Medicine is one of the oldest neurosurgical departments in Korea, and it is a center of academic leadership in neurosurgery. In September 1957, the department was established by Bo Sung Sim, and it has produced many leaders of neurosurgery in Korea. Chairmen Bo Sung Sim, Kil Soo Choi, Dae Hee Han, and Byung-Kyu Cho each brought special skills and talents to the development of the department. The current and fifth chair, Hyun Jib Kim, assumed the chairmanship in July 2000. The department comprises 11 full-time faculty members, 5 fellows, and 14 residents. More than 1,700 neurosurgical procedures are performed annually in four operating theaters. A gamma knife was installed in 1997, and approximately 200 gamma knife procedures are performed each year. In addition to clinical activities, research and education for graduate and postgraduate students are also particular strengths of the department. This article traces the clinical, academic, and scientific development of the department, its present activities, and its future direction.

Fatal hemorrhage from rupture of the intracranial internal carotid artery caused by aspergillus arteritis

To the best of our knowledge, this is the first reported case of combined intracranial and extracranial hemorrhage due to aspergillus cerebral arteritis. Knowledge of the imaging and the importance of early diagnosis and treatment are emphasized. A 78 year old man developed progressive right-sided visual impairment and diplopia. Magnetic resonance imaging demonstrated a mass lesion located in the right orbital apex, with extension to the cavernous sinus and the right middle cranial fossa. Cerebral angiography showed no aneurysmal dilatation. He was scheduled for transnasal biopsy. However, the patient died of massive epistaxis and intracranial hemorrhage. Postmortem examination revealed an aspergillus granuloma of the orbit and the skull base involving the intracranial and extracranial internal carotid artery. Aspergillus fumigatus was identified by culture. The characteristic feature of the fungal infection is a low-intensity signal on T2-weighted magnetic resonance images. This finding may be useful in diagnosing fungal infection.

Cerebral aspergillosis in a liver transplant recipient: a case report of long-term survival after combined treatment with liposomal amphotericin B and surgery

Cerebral aspergillosis is a life-threatening complication in liver transplant recipients, with mortality rates approaching 100%; treatment with amphotericin B is of limited efficacy because of its poor distribution in the cerebrospinal fluid and its systemic side effects. We report the case of a liver transplant recipient who developed recurrent cerebral Aspergillus fumigatus infection, and was successfully treated by combined surgical excision of the lesion and administration of liposomal amphotericin B. This first report of long-term complication-free survival in a liver transplant recipient suggests that therapy with liposomal amphotericin B may reduce the risk of recurrence of cerebral aspergillosis in these immunocompromised patients.

The spectrum of orbital aspergillosis: a clinicopathological review

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Invasive aspergilloma of the frontal base causing internal carotid artery occlusion

BACKGROUND

Aspergilloma of the nasal cavity or paranasal sinuses rarely extends through the skull base into the intracranial space.

PATIENT

The patient was a 79-year-old man in a nonimmunosuppressive state who had an invasive aspergilloma of the base of the frontal lobe.

CLINICAL COURSE

The patient, whose initial symptom was a visual disturbance, eventually developed an occlusion of the right internal carotid artery and died. The diagnosis was established by a transsphenoidal biopsy.

CONCLUSIONS

A rare case of invasive aspergilloma of the frontal base is described with emphasis on the findings of low-intensity mass on the T2-weighted magnetic resonance imaging (MRI). The prognosis in this disease is very poor. Early diagnosis and surgical treatment, combined with postoperative antifungal drug therapy, would have improved the outcome.