Epidural abscess caused by Schizophyllum commune: A rare case of rhinogenic cranial complication by a filamentous basidiomycete

A Case Report of Frontal Sinus Abscess Complicated by Epidural Abscess with a Literature Review

Inflammation of the frontal sinus is a relatively common clinical condition among paranasal sinusitis and is curable through anti-infection treatments, with a rare progression to frontal sinus abscess. An even rarer complication is the development of intracranial epidural empyema secondary to frontal sinus abscess. In this report, we describe a case of a 14-year-old male with a frontal sinus abscess that led to intracranial infection and was complicated by an epidural abscess misdiagnosed as an epidural hematoma. The primary symptoms were headache, dizziness, and fever. Following combined antibiotic therapy and surgical intervention, including maxillary and frontal sinus window drainage, the patient was cured. A follow-up period of three months showed no recurrence, indicating a favorable outcome.

Case report: Diagnosis and treatment of delayed epidural pyogenic abscess after brain tumor operation: a report of 5 cases and review of the literature

Objective

To explore the clinical manifestations and treatment of delayed epidural pyogenic abscess after brain tumor surgery.

Method

To retrospectively analyze the medical records of 5 patients with delayed epidural pyogenic abscess after brain tumor surgery in our hospital from January 2010 to December 2020, including clinical manifestations, laboratory results, imaging findings, treatment measures, prognosis, etc. The causes of epidural abscesses were analyzed, and the treatment methods and prognosis were evaluated.

Result

Among the 5 cases, there were 4 male and 1 female patient, aged 52-75 years. Three cases were gliomas and 2 cases were meningiomas. Four cases received postoperative radiotherapy, and 1 case had open frontal sinus during operation. None of the surgical incisions were infected. The time between the tumor surgery and the discovery of an epidural abscess was 1.5 to 24 months. All 5 patients had headaches, 1 case had a fever, and 2 cases had limb dysfunction. Three cases had elevated blood inflammatory markers. MRI- DWI showed restricted diffusion. All 5 patients underwent surgery, 4 patients had bone flap removed, and 1 patient had bone flap retained. Bacterial culture was positive in 3 cases and negative in 2 cases. All 5 cases were cured, followed up for 1.5-9 years, and no epidural abscess recurred.

Conclusion

The clinical manifestations and laboratory results of delayed epidural pyogenic abscess after brain tumor surgery are not specific, but MRI-DWI has specificity. Postoperative radiotherapy for brain tumors and intraoperative opening of the frontal sinus may be associated with delayed epidural pyogenic abscess. For patients with normal skin flap and no serious inflammation of the bone flap, clinicians can attempt to preserve the bone flap.

Pneumonia due to Schizophyllum commune in a Patient with Acute Myeloid Leukemia: Case Report and Literature Review

Schizophyllum commune is a mold in phylum Basidiomycota and is an uncommon human pathogen. Sinusitis and allergic bronchopulmonary mycosis are the two major diseases caused by S. commune. Although there have been several reports of invasive fungal diseases, most of them were invasive sinusitis. We present a case of invasive fungal pneumonia due to S. commune, developed in a patient with acute myeloid leukemia presenting neutropenic fever. The diagnosis was made by characteristic macroscopic and microscopic findings of fungal isolate and was confirmed via sequencing of internal transcribed spacer region. The patient was improved after 8 weeks of antifungal therapy based on the susceptibility result. We propose that S. commune should be considered as an emerging pathogen of invasive fungal pneumonia when a patient is under immunocompromised state. We also reviewed global literatures focused on the invasive fungal diseases caused by S. commune.

Recent developments in less known and multi-resistant fungal opportunists

Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.

Hypertrophic pachymeningitis caused by Schizophyllum sp.: a novel case report

BACKGROUND

The pathogenic fungus Schizophyllum sp. can cause allergic fungal rhinosinusitis and allergic bronchopulmonary mycosis in humans. Sinus and lung infections due to Schizophyllum sp. have been reported globally; however, no case of hypertrophic pachymeningitis due to this pathogen has been reported yet. Herein, we describe for the first time, a case of hypertrophic pachymeningitis due to Schizophyllum sp.

CASE PRESENTATION

A 69-year-old woman visited the hospital with chief complaints of headache, right trigeminal neuralgia (third branch), ataxic gait, and deafness in the right ear. Magnetic resonance imaging revealed a tumor in the right sphenoidal sinus and thickening of the dura mater surrounding the right porus acusticus internus. Endoscopic sinus surgery and neuroendoscopic biopsy were performed to remove sinus lesions and intracranial lesions, respectively. Both pathological specimens showed findings indicative of filamentous fungi on Grocott's staining. DNA sequencing with the sinus specimen revealed Schizophyllum sp. as the causative pathogen, consistent with the diagnosis of fungal sinusitis and hypertrophic pachymeningitis. Intravenous liposomal amphotericin B was started, but owing to lack of improvement, the treatment was switched to intravenous voriconazole. We observed improvements in both radiological findings and symptoms. However, the symptoms exacerbated again when the trough level of voriconazole decreased. Upon increasing the voriconazole dose, a higher trough level was obtained and the symptoms improved.

CONCLUSION

Our study suggests that when symptoms of central nervous system infection due to Schizophyllum sp. do not improve with liposomal amphotericin B, voriconazole can be administered at high trough levels to improve the symptoms.

Schizophyllum commune sphenoidal sinusitis as presentation of a non-Hodgkin Lymphoma

Schizophyllum commune is a basidiomycetes worldwide distributed that has emerged as cause of invasive infections in immunosuppressed patients. We present a case of a man who was simultaneously diagnosed with a small cell non-Hodgkin lymphoma and a sphenoid sinusitis by S. commune. Intraoperative observation and histology description were crucial to consider an alternative diagnosis to mucormycosis suggested by the MRI. The diagnosis was made based on PCR identification and sequencing.

Human infections due to Schizophyllumcommune: Case report and review of the literature

Schizophyllumcommune is an environmental basidiomycetous fungus, causing occasional, predominantly respiratory, infections in humans. Although S. commune is considered an emerging pathogen, some authors pointed out the possibility that the increase in the diagnosed cases may be also due to recent advances in diagnostic technologies now allowing a more prompt and precise identification at the species level. Here we describe the first Italian case of chronic non-invasive fungal rhinosinusitis due to S. commune in an immunocompetent subject and update the literature review on S. commune sinusitis published between 2012-2019. A timely diagnosis is important to avoid local and systemic complications due to infection with this fungus. In our case, prompt identification at species level was only possible with the use of MALDI-TOF mass spectrometry and confirmed by sequence analysis of ribosomal DNA ITS regions, due to the difficulty in achieving a correct and rapid identification using routine morphological analysis.