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

Social determinants of health as drivers of fungal disease

Disparities in social determinants of health (SDOH) play a significant role in causing health inequities globally. The physical environment, including housing and workplace environment, can increase the prevalence and spread of fungal infections. A number of professions are associated with increased fungal infection risk and are associated with low pay, which may be linked to crowded and sub-optimal living conditions, exposure to fungal organisms, lack of access to quality health care, and risk for fungal infection. Those involved and displaced from areas of armed conflict have an increased risk of invasive fungal infections. Lastly, a number of fungal plant pathogens already threaten food security, which will become more problematic with global climate change. Taken together, disparities in SDOH are associated with increased risk for contracting fungal infections. More emphasis needs to be placed on systematic approaches to better understand the impact and reducing the health inequities associated with these disparities.

Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review

OBJECTIVE

We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease.

DATA SOURCES

Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language.

REVIEW METHODS

Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each).

CONCLUSIONS

The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases.

IMPLICATIONS FOR PRACTICE

Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

A Clinico-Pathological Study of Allergic Fungal Rhinosinusitis at a Tertiary Care Center of Western Rajasthan

Allergic fungal rhinosinusitis (AFRS) is a non-invasive fungal sinusitis resulting from an immunologic response to the presence of extra mucosal fungal hyphae in the sinuses. Here we studied clinicopathological characteristics of AFRS among patients of chronic rhinosinusitis with nasal polyposis who underwent Functional Endoscopic Sinus Surgery (FESS) at a tertiary care in western Rajasthan. Standard ethical protocol was followed for the present study. We did a prospective study on admitted patients of chronic rhinosinusitis with nasal polyposis in the department of Otorhinolaryngology and Head & neck surgery, Dr. S. N. Medical College, Jodhpur from January 2018 to August 2019, who underwent FESS. The patient's history, clinical and endoscopic findings with radiological features were recorded. Biopsy specimens were sent for fungal staining, culture, and histopathology. As per Bent and Kuhn criteria, 25 cases out of 100 were diagnosed as AFRS, mean age was 27.46 ± 13.36. Nasal obstruction and nasal discharge were the most common symptoms. On histopathological examination fungal hyphae found in 18 cases (72%), allergic mucin in 25 cases (100%) and eosinophilic infiltrate in 20 cases (80%). Fungal culture positive in 15 cases (60%) of AFRS. In which aspergillus flavus present in 12 (80%). Allergic fungal rhinosinusitis should be considered as an important differential diagnosis in patients with chronic rhinosinusitis with nasal polyposis and for this surgery should be the treatment of choice.

Can imaging suggest the aetiology in skull base osteomyelitis? A systematic literature review

Purpose

To assess differentiating features between bacterial, Aspergillus, and Mucor skull base osteomyelitis (SBO) with regard to clinical presentation and imaging appearances.

Material and methods

A literature search was performed in April 2020 for studies on SBO with a minimum sample size of 10 patients. Studies that reported presenting symptoms, cross-sectional imaging findings, complications, and mortality were included in the analysis. The quality of included articles was tested using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A data extraction form was used to retrieve relevant parameters from each of the articles.

Results

Thirteen articles were included in the final analysis. Diabetes mellitus was the most common predisposing factor (12.5-91.0%). Presenting complaints in all bacterial SBO studies were otogenic, while fungal SBO patients had nasal/ocular complaints. Rates of mortality and surgical intervention in the fungal group were 50-100% and 50%, respectively, as compared to the bacterial group – 7-87% and 10%, respectively. On imaging, the site of initial infection in bacterial SBO was the external auditory canal, while in fungal SBO it was the paranasal sinus. The incidence of orbital extension was < 5% in bacterial and 44-70% in fungal SBO, among which Mucor had rates of 65-70%. Bone erosion was less extensive in bacterial SBO, and the patterns differed. The highest incidence of vascular involvement and non-enhancing lesions (23-36%) was seen in Mucor. Aspergillus showed highest sino-cranial extension (52-55%) and homogenous bright enhancement.

Conclusions

Systematic analysis of the clinico-radiological parameters in each of the studies revealed differences in presentation, clinical course, extension, bone erosion, and enhancement.

Role of Voriconazole in the Management of Invasive Central Nervous System Aspergillosis: A Case Series from a Tertiary Care Centre in India

Invasive central nervous system (CNS) aspergillosis is acquired by either hematogenous dissemination or direct spread from a sinus infection. We describe a series of nine patients with CNS aspergillosis from a tertiary care teaching institute in North India who were treated with voriconazole alone or in combination with surgery. All patients who had clinical and radiological features consistent with fungal CNS infection, showed the presence of septate hyphae on histopathology/microscopy and were either culture positive for Aspergillus spp. or had serum galactomannan positivity were diagnosed as CNS aspergillosis. Clinical features, risk factors, diagnostic modalities, treatment details and outcome at last follow-up were recorded for all patients diagnosed with CNS aspergillosis. A total of nine patients were diagnosed with CNS aspergillosis. The median duration of presentation at our hospital was six months (IQR-2-9 months). Six patients had concomitant sinus involvement, while two patients had skull-base involvement as well. All patients were treated with voriconazole therapy, and three of these patients underwent surgery. All but one patient survived at the last follow-up (median duration was 14 months (IQR- 8-21.5). Two patients had complete resolution, and voriconazole was stopped at the last follow-up, and the rest of the patients were continued on voriconazole. Of the six patients who were continued on voriconazole, all but one had more than 50% radiological resolution on follow-up imaging. Invasive CNS aspergillosis is an important cause of CNS fungal infection that is often diagnosed late and requires long-term voriconazole-based therapy.

Clinicians' challenges in managing patients with invasive fungal diseases in seven Asian countries: An Asia Fungal Working Group (AFWG) Survey

BACKGROUND

Invasive fungal diseases (IFD) are a serious threat, but physicians in Asia lack access to many advanced diagnostics in mycology. It is likely that they face other impediments in the management of IFD. A gap analysis was performed to understand the challenges Asian physicians faced in medical mycology.

METHODS

The Asia Fungal Working Group (AFWG) conducted a web-based survey on management practices for IFD among clinicians in China, India, Indonesia, Philippines, Singapore, Taiwan and Thailand.

FINDINGS

Among 292 respondents, 51.7% were infectious disease (ID) specialists. Only 37% of respondents had received formal training in medical mycology. They handled only around 2-4 proven cases of each fungal infection monthly, with invasive candidiasis the most common. For laboratory support, the majority had access to direct microscopy (96%) and histopathology (87%), but galactomannan and azole levels were available to 60% and 25% of respondents, respectively. The majority (84%) used clinical parameters for treatment response monitoring, and 77% followed the Infectious Diseases Society of America guidelines. The majority (84%) did not use the services of an ID physician. Where febrile neutropenia was concerned, 74% of respondents used the empirical approach. Only 30% had an antifungal stewardship program in their hospital. Eighty percent could not use preferred antifungals because of cost.

INTERPRETATION

The survey identified inadequacies in medical mycology training, non-culture diagnostics, access to antifungal drugs, and local guidelines as the major gaps in the management of IFDs in Asian countries. These gaps are targets for improvement.

Holohemispheric Invasive Aspergillus Granulomatous Cerebritis of the Brain

BACKGROUND

Invasive aspergillosis of the central nervous system, a saprophytic infection with a unique vascular tropism, carries the burden of increased morbidity and mortality. Early clinical and imaging findings can masquerade as an innocuous condition before a secondary inexorable progression. We highlight the clinical and imaging phenotype of a patient with fatal invasive granulomatous aspergillosis.

CASE DESCRIPTION

A 39-year-old man presented with progressive weakness of the left upper and lower limb for 4 months. Imaging demonstrated right holohemispheric extensive, numerous, confluent, ill-defined, T2 hypointense foci with moderate perilesional edema. Numerous foci of microhemorrhages with cortical asymmetric mineralization were seen. Post-contrast heterogeneous, variegate, punctiform enhancement of the lesions was observed extending to the ventricular margins. Volume loss of the left cerebral peduncle and ipsilateral long white matter descending tracts was noted. Histopathologic examination of a stereotactic biopsy specimen from the frontal region lesion showed dense inflammatory infiltrate with granulomas, a few in a perivascular distribution and branching septate hyphae resembling Aspergillus. The patient was initiated on antifungal therapy and in the following week, he had progressive drowsiness. The patient succumbed the next day.

CONCLUSIONS

Diffuse holohemispheric, progressive presentation of a granulomatous form of invasive aspergillosis is a rare entity. The miliary pattern of heterogenous enhancement, holohemispheric conglomerate T2 hypointensities, interspersed hemorrhage, juxtacortical punctate T2 hyperintense foci, low perfusion, and the relative absence of diffusion abnormality are distinctive features. Early diagnosis of this atypical imaging phenotype of Aspergillus infection and appropriate treatment is critical for better prognosis.

Basilar Occlusion and Rupture Secondary to Rare Fungal Sinusitis

BACKGROUND

Intracranial vascular infections of fungal etiology are extremely rare. Most cases occur in immunocompromised patients with invasive fungal disease, most commonly originating in the paranasal sinuses or the lungs. Granulomatous invasive rhinosinusitis, which is extremely rare in North America, has been reported to affect immunocompetent patients in most cases, and its causative strain has potential to invade the intracranial arteries. We present a rare case of basilar artery rupture and infarction secondary to granulomatous invasive rhinosinusitis.

CASE DESCRIPTION

A 50-year-old man in Florida presented with ischemic symptoms and a 6-month history of headache, dizziness, and falls. After biopsy, the patient developed subarachnoid hemorrhage and thrombosis. Several thrombectomy attempts were performed, resulting in persistent occlusion of the basilar artery and subsequent comatous state. After discussion with the patient's family, compassionate weaning and autopsy were authorized.

CONCLUSIONS

Invasive fungal rhinosinusitis is more frequent nowadays owing to increased use of immunosuppressive therapies. However, it is still a disease that mostly affects immunocompromised patients. The development of new microbiologic investigation techniques has enabled the discovery of fungal diseases that can also affect immunocompetent hosts, such as granulomatous invasive rhinosinusitis. This is an extremely rare condition in North America, with very few cases documented in the last few decades.

Epidemiology and clinical characteristics of invasive mould infections: A multicenter, retrospective analysis in five Asian countries

Formal, large-scale, multicenter studies of invasive mould infection (IMI) in Asia are rare. This 1-year, retrospective study was designed to assess the incidence and clinical determinants of IMI in centers in five countries (Thailand, Taiwan, Singapore, China, India). Patients treated in a single year (2012) were identified through discharge diagnoses, microbiology, and histopathology logs, and entered based on published definitions of IMI. A total of 155 cases were included (median age 54 years; 47.7% male). Of these, 47.7% had proven disease; the remainder had probable IMI. The most frequent host factors were prolonged steroid use (39.4%) and recent neutropenia (38.7%). Common underlying conditions included diabetes mellitus (DM; 30.9%), acute myeloid leukemia (19.4%), and rheumatologic conditions (11.6%). DM was more common in patients with no recent history of neutropenia or prolonged steroid use (P = .006). The lung was the most frequently involved site (78.7%), demonstrating a range of features on computed tomography (CT). Aspergillus was the most common mould cultured (71.6%), primarily A. fumigatus and A. flavus, although proportions varied in different centers. The most often used antifungal for empiric therapy was conventional amphotericin. Ninety-day mortality was 32.9%. This is the first multicenter Asian study of IMI not limited to specific patient groups or diagnostic methods. It suggests that DM and rheumatologic conditions be considered as risk factors for IMI and demonstrates that IMI should not be ruled out in patients whose chest features on CT do not fit the conventional criteria.

Diagnosis of filamentous fungi on tissue sections by immunohistochemistry using anti-aspergillus antibody

Identification based on histology alone has limitations as Aspergillus species share morphology with other filamentous fungi. Differentiation of Aspergillus species from hyalohyphomycetes and dematiaceous fungi is important as the antifungal susceptibility varies among different species and genera. Given these problems, ancillary techniques are needed to increase specificity. Our aim was to study the utility of immunohistochemistry (IHC) with anti-Aspergillus antibody in the identification of Aspergillus species and to differentiate them from other filamentous fungi. Fifty formalin fixed, paraffin embedded tissue sections including 47 from cases of culture proven filamentous fungi, 3 from colonies of cultures of hyalohyphomycetes, and 11 smears from cultures were subjected to IHC studies using polyclonal rabbit anti-Aspergillus antibody (Abcam, UK) after antigen retrieval. The IHC on tissue sections was positive in 88% cases involving culture proven Aspergillus species. There was no cross reactivity with Mucorales species, Candida species, dematiaceous fungi and hyalohyphomycetes. Hence immunohistochemistry can be used as an ancillary technique for the diagnosis of Aspergillus species.

Fungal infections of the central nervous system

The epidemiology of invasive fungal infections in immunocompromised patients is rapidly changing. Several of the fungi have worldwide distribution. However, some have specific geographical distribution. Sinocranial aspergillosis, mostly described from countries with temperate climates, occurs mostly in otherwise immunocompetent individuals Most of the systemic fungal pathogens have been associated with central nervous system (CNS) involvement. The major advances in CNS fungal infections are in the pathobiology, new diagnostic tools, and new therapies. In spite of these developments, there is still considerable delay in the diagnosis of CNS fungal infection. CNS fungal infections are associated with considerable morbidity and mortality. To achieve good outcomes early diagnosis and early institution of appropriate therapies are the key issues.

Aspergillus osteomyelitis of the lumbar spine complicated with orbital apex syndrome: A potential role of the Batson's plexus in disease propagation

We report a rare case of orbital apex syndrome following epidural steroid injections of the lumbar spine in an immunocompetent individual with osteomyelitis and discitis caused by Aspergillus fumigatus. We suspect that the craniospinal venous system, also known as the Batson's plexus, was the main route for steroid-facilitated disease propagation from the spine to intracranial structures.

Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis

Management of invasive fungal sinusitis includes both surgery and antifungal chemotherapy. To compare the efficacy of amphotericin B and itraconazole used alone in the management of chronic invasive fungal sinusitis. A prospective randomized unblinded study was conducted in the Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India during December 2006 to June 2008. 26 immunocompetent patients were randomly divided into two groups-group A-received amphotericin B and group I-received itraconazole in conventional doses. The response to treatment was judged on the basis of symptomatic and radiologic resolution. Seven patients had complete cure (5/16-gr I; 2/10-gr A); Eleven patients had persistent disease (7/16-group-I; 4/10 in group A); four relapses were noted (3/16 in group I and 1/10 in group A); 3 deaths occurred; one patient was lost to follow up. Relative risk analysis did not show any statistically significant difference between the two drugs as regards their efficacy. Itraconazole and amphotericin B both have been found to be equally efficacious in the management of invasive fungal sinusitis. Itraconazole however, has fewer side effects compared to amphotericin B.

Intracranial Aspergillus granuloma

Intracranial fungal granulomas are rare and of the histologically verified granulomas, Aspergillus spp. is the commonest causative fungal pathogen. Most of the reported large series of aspergillus granulomas are from countries with temperate climate like India, Pakistan, Sudan, and Saudi Arabia. In contrast to disseminated aspergillosis that occurs in immunosuppressed individuals, most of the intracranial aspergillus granulomas are reported in immunocompetent individuals. The temperature, humidity, high spore content in the atmosphere during ploughing, and occupation as agricultural worker are implicated in the pathogenesis. The sinocranial spread is the most common route of intracranial extension. Extracerebral firm fibrotic lesions and skull base lesions are common. Extensive fibrosis and large number of multinucleated giant cells are the characteristic histological features and these pathological features have therapeutic relevance.

Invasive aspergillosis in developing countries

To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.

Fungal rhinosinusitis: a clinicopathological study from South India

Fungal rhinosinusitis (FRS) is uncommon and accounts for 6-12% of culture or histologically proven chronic sinusitis. FRS may be acute or chronic. The aim of this paper was to study the histological features that contribute to the diagnosis and sub typing of FRS, using a retrospective review of all paranasal sinus mucosal biopsies from January 2005 to December 2008. The clinical features, predisposing conditions, imaging findings, and extent of the lesion were noted. The slides were reviewed with hematoxylin and eosin, Gomori's methenamine silver, and periodic acid Schiff stains. Culture reports were obtained wherever material was subjected to culture. There were 63 biopsies diagnosed as FRS (45.7%) out of 138 biopsies of chronic sinusitis in the study period. The FRS was classified as allergic in 15 (23.8%), chronic non-invasive (sinus mycetoma) in 1 (1.6%), chronic invasive in 10 (15.87%), granulomatous invasive in 19 (30%), and acute fulminant in 18 (28.5%) biopsies or surgical resections. Predisposing conditions were identified in 19 patients with diabetes mellitus as the commonest. Seventeen of the 18 patients with acute fulminant FRS had predisposing conditions. As per the results, the characteristic histological features were allergic mucin in allergic, fungal ball in chronic non-invasive, sparse inflammation and numerous hyphae in chronic invasive, non caseating granulomas with dense fibrosis in granulomatous invasive, and infarction with suppuration in acute fulminant FRS. Aspergillus sp. was the commonest etiologic agent. To conclude, predisposing risk factors were more common in invasive FRS than in non-invasive sinusitis and Aspergillus species was the most common etiologic agent.

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.

Intracranial Aspergilloma in Immunocompetent Patients Successfully Treated with Radical Surgical Intervention and Antifungal Therapy – Case Series

Introduction: Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients with a high mortality. Surgical excision of the intracranial lesion combined with oral voriconazole has been proposed to improve the outcome in immunocompromised patients. Itraconazole has been considered not to be effective because of poor penetration into the brain tissue. We report the long-term outcome of 3 cases of intracranial aspergilloma in immunocompetent patients who were successfully treated with radical surgery combined with oral itraconazole. Materials and Methods: This is a retrospective study in which chronic invasive intracranial aspergilloma was successfully treated in 3 apparently immunocompetent patients and followed-up for more than 5 years. Results: Near complete or radical surgical removal of this localised chronic invasive intracranial aspergilloma whenever possible is the definitive treatment. When combined with the oral antifungal drug itraconazole, the management regimen is effective in achieving near complete long-term cure of more than 5 years. Oral itraconazole 200 mg twice daily should be given for a prolonged period of at least 6 months. Conclusion: In chronic invasive intracranial aspergilloma in an immunocompetent patient, it was suggested that radical excision of the intracranial aspergilloma combined with oral antifungal drug belonging to triazole group that can be either itraconazole or voriconazole given for a period of 6 months was likely to improve the long-term outcome. Key words: Central nervous system aspergillosis, Aspergilloma, Itraconazole, Voriconazole

[Invasive aspergillosis of the skull base with orbit infiltration]

BACKGROUND

[corrected] Aspergillosis of the paranasal sinuses is subdivided into noninvasive and invasive types, depending on invasion of the tissue. The invasive form often occurs in immunodeficient patients and can be divided further into granulomatous, chronic invasive, and acute fulminating forms.

CASE REPORT

We report the clinical course of an immunosuppressed 64-year-old male with invasive aspergillosis originating from the sphenoid sinus with infiltration of the orbit and intracranial extension into the cavernous sinus. The patient was referred to our hospital with loss of vision, ptosis, and ophthalmoplegia of 3-month duration. Additionally he suffered from diabetes mellitus II and kidney failure after kidney transplantation. After CT scanning, endonasal sinus debridement and decompression of the orbit were carried out immediately. Histology revealed invasive aspergillosis. Postoperatively, both systemic and local antimycotic therapy and antibiotic treatment were performed. According to recommendations of the Undersea and Hyperbaric Medicine Society, cerebral abscess is a certain indication of hyperbaric oxygenation. We decided to attempt therapy for that as well. The patient died 3 weeks after surgical intervention due to carotid dissection.

CONCLUSION

Invasive aspergillosis of the paranasal sinuses and the skull base of immunsuppressed patients is usually lethal because of intracranial complications. Therefore, fast diagnosis using CT and MRI and surgical and antimycotic therapy are necessary.

Pathology of fungal infections of the central nervous system: 17 years' experience from Southern India

AIMS

To describe the pathology of central nervous system (CNS) fungal infections with particular reference to India.

METHODS AND RESULTS

This was a retrospective study from 1988 to 2004 constituting 130 cases. The diagnosis was based on morphology of biopsy/autopsy material. These included aspergillosis (n=73), zygomycosis (n=40), cryptococcosis (n=2), rhodotorulosis (n=1), candidiasis (n=5), maduramycosis (n=1), pheohyphomycosis (n=3) and mixed infections (n=5). Predisposing risk factors were present in 49 (38%) patients only. The majority of the patients were immunocompetent. The commonest risk factor was diabetes mellitus, the commonest route of infection was from a contiguous site and the commonest pathology was granuloma. Culture positivity was seen in only 31%.

CONCLUSION

Environmental factors in tropical countries such as India play a significant role in the pathogenesis of CNS fungal infections.

Cerebral zygomycosis

Fifty-six patients with cerebral zygomycosis (mucormycosis) were seen during the period 1971-2001 in two tertiary care hospitals located in south India with tropical climate and catering to neurological diseases. Forty-four patients had rhinocerebral and twelve patients had isolated central nervous system (CNS) zygomycosis. Of these, ten were culture proven (Rhizopus oryzae in eight and Mucor in two); 30 were diagnosed as probable and 16 were diagnosed possible; mixed infections were seen in three patients. Diabetes mellitus was the predisposing condition in a majority (31/44) of patients with the rhinocerebral form of zygomycosis. The tissue obtained at biopsy/autopsy in either form showed necrotic/infarcted tissue with neutrophilic infiltration with broad non-septate hyphae showing irregular branching. The outcome was poor despite surgical excision and antifungal therapy. The high concentration of spores in a mouldy environment, the bird population and improper disposal of hospital waste may facilitate healthy hosts presenting with primary CNS disease.

Overview of fungal rhinosinusitis

The incidence of fungal rhinosinusitis has increased to such extent in recent years that fungal infection should be considered in all patients with chronic rhino sinusitis. In India though the disease was reported earlier only from northern regions of this country, nowadays the disease is increasingly diagnosed from other parts as well. The disease has been categorized with possible five types: acute necrothing (fulminant), chronic invasive, chronic granulomatous invasive, fungal hall (sinus mycetoma), allergic. The first three types are tissue-invasive and the last two are non-invasive fungal rhinosinusitis. However, the categorization is still controversial and open to discussion. Chronic fungal rhinosinusitis can occur in otherwise healthy host and Aspergillus flavus is the common etiological agent in Indian scenario. The pathophys iologic mechanism of the disease remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of two. Early diagnosis may prevent multiple surgical procedures and lead to effective treatment. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence oj precipitating antibody correlates well with disease progression or recovery. The most immediate need regarding management is to establish the respective roles of surgery and antifungal therapy. Non-invasive disease requires surgical debridement and sinus ventilation only, though, additional oral or local corticosterold therapy may be beneficial in allergie type. For invasive disease, the adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole has been found as an effective drug in such situation. Patients with acute neerotizing type require radical surgery and amphotericin B therapy.

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.