Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient

A Rare Case of Invasive Central Nervous System Aspergillus niger in a Previously Immunocompetent Patient After Corticosteroid Treatment for COVID-19

Aspergillus is a ubiquitous saprophyte found in air, soil, and organic matter. Humans inhale the spore form of the fungus, but manifestations of the disease are typically predominantly seen in immunocompromised patients. Invasive central nervous system (CNS) aspergillosis is even more uncommon, and epidemiological data is sparse, particularly in immunocompetent patients. We report the case of a 67-year-old previously immunocompetent female with no known comorbidities who was treated with corticosteroids for COVID-19 one month prior to admission for altered mental status (AMS). Subsequent imaging and biopsy demonstrated invasive CNS Aspergillus niger. Though a rare cause of AMS in immunocompetent patients, this report draws attention to the detrimental immunosuppressive effects of corticosteroid therapy in COVID-19.

Transorbital Endoscopic Approach to the Pterygopalatine Fossa: A Less Invasive Alternative to Traditional Access

PURPOSE

The purpose of this article and accompanying video is to demonstrate a transorbital endoscopic approach for accessing the pterygopalatine fossa (PPF). This technique does not require a skin incision, avoids dissection of critical neurovascular structures, and utilizes a comparatively small osteotomy. The 2 cases presented in this article highlight the utility of a transorbital endoscopic approach for accessing an anatomic region that has traditionally required more invasive techniques to reach.

METHODS

Description of surgical technique with 2 illustrative clinical cases and accompanying surgical video.

RESULTS

Surgical technique: A trans-conjunctival approach is taken to the inferior orbital rim, and a subperiosteal dissection is propagated posteriorly. The bone of the posterior orbital floor is then deroofed, and the superior portion of the posterior wall of the maxillary sinus is removed, allowing access to the PPF for an incisional biopsy.

CASE

A 76-year-old male with a history of left cheek squamous cell carcinoma presented with progressive V2 paresthesia and an abnormally enhancing lesion in the left PPF on MRI.

CASE

A 58-year-old male with no significant medical history presented with left facial numbness (V1-V3), ptosis, an abduction deficit, and decreased hearing. Contrast-enhanced MRI demonstrated an abnormally enhanced lesion in the left PPF extending to Meckel's cave.The transorbital approach described was used to successfully obtain a diagnostic biopsy in both cases.

CONCLUSIONS

These cases highlight the utility of a transorbital endoscopic approach to the PPF as a less morbid alternative to traditional access. Patient selection is key to identifying appropriate cases.

Management of granulomatous cerebral aspergillosis in immunocompetent adult patients: a review

Cerebral aspergillosis, is an infrequent, opportunistic infection of the central nervous system that accounts for 5-10% of all intracranial fungal pathology. It is uncommon in immunocompetent patients and has a significant disease burden, with high morbidity and mortality, even with appropriate treatment. Basic principles of abscess management should be employed, including aspiration and targeted anti-fungal therapy for 12-18 months. However, reported outcomes with a purely minimally invasive approach are poor and there should be a low threshold for surgical excision, especially in resource poor settings and in patients with deteriorating neurology harbouring sizeable masses. Evidence favouring gross total excision over subtotal resection is lacking, however. It is notable that these recommendations are largely based on retrospective case series and isolated case reports. There is a need therefore for international collaboration to evaluate management strategies for immunocompetent patients with cerebral aspergillosis.

Disseminated Aspergillosis due to Aspergillus niger in Immunocompetent Patient: A Case Report

Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients. Many cases of pulmonary, cutaneous, cerebral, and paranasal sinus aspergillosis in immunocompetent patient were defined in literature but disseminated aspergillosis is very rare. Here we present an immunocompetent case with extrapulmonary disseminated aspergillosis due to Aspergillus niger, totally recovered after effective antifungal treatment with voriconazole.