Invasive Central Nervous System Aspergillosis: Cure with Liposomal Amphotericin B, Itraconazole, and Radical Surgery???Case Report and Review of the Literature

[A case of noninvasive sinus aspergillosis showing orbital apex syndrome]

A 78-year-old man was admitted to our hospital with headache, nasal pain, left-sided ptosis, loss of visual field in his left eye, and left ophthalmoplegia. Serum levels of beta-D-glucan were elevated. T1-weighted magnetic resonance imaging with gadolinium enhancement showed hyperintense lesions in the left orbital apex and dura mater of the left middle cranial fossa. A few days later, culture of specimens collected by surgical debridement from the left sphenoidal sinus revealed numerous branching hyphae. The aspergillus antigen was found in the cerebrospinal fluid (CSF). Therefore, aspergillosis causing orbital apex syndrome was diagnosed. Administration of amphotericin B prevented further worsening of the patient's infection. Although noninvasive sinus aspergillosis showed that fungus did not destroy tissues in general, the condition resulted in intracranial impairments observed in this case, including orbital apex syndrome and hypertrophic pachymeningitis. Furthermore, detection of the aspergillus antigen in CSF was a clue for the diagnosis of aspergillosis, and administration of antifungal drugs in the early stages of infection was an effective treatment

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