Oral voriconazole for invasive fungal skull base infection

Rare Orbital Infections ~ State of the Art ~ Part II

Infections of the orbit and periorbita are relatively frequent. Identifying unusual organisms is crucial because they can cause severe local and systemic morbidity, despite their rarity. Opportunistic infections of the orbit should be considered mainly in debilitated or immunocompromised patients. The key to successful management includes a high index of suspicion, prompt diagnosis, and addressing the underlying systemic disease. This review summarizes unusual infectious processes of the orbit, including mycobacterial, fungal, and parasitic infections, as well as their pathophysiology, symptoms, signs, and treatment.

Acute chiasmal abscess resulting from perineural extension of invasive sino-orbital aspergillosis in an immunocompetent patient

OBJECTIVE

Intracranially invasive sino-orbital aspergillosis is a rare entity seen predominantly in immunocompromised individuals. We report a unique case of an acute chiasmal abscess resulting from perineural extension of an indolent invasive sino-orbital aspergillosis in an immunocompetent patient.

CASE DESCRIPTION

A 61-year-old healthy Ukrainian man presented with severe left retro-orbital pain and a gradual ipsilateral monocular vision loss with rapid progression to a contralateral temporal visual field cut. He was found to have an intracranially invasive sino-orbital Aspergillus fumigatus infection with perineural extension along the optic nerve complicated by an acute chiasmal abscess.

RESULTS

The patient was managed with surgical debridement and adjuvant antifungal chemotherapy. The patient's life and vision were preserved.

CONCLUSIONS

The case demonstrates that it is possible to successfully control advanced intracranial aspergillosis with tissue-sparing surgery and adjuvant antifungal chemotherapy in immunocompetent individuals.

Aspergillus petrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Background:

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

Case report:

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Conclusion:

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.