Intracranial invasive aspergillosis originating in the sphenoid sinus: a successful treatment with high-dose itraconazole in three cases

The Outcome of Endoscopic Sinus Surgery for Orbital Apex Syndrome Secondary to Sinusitis in a Tertiary Care Center-Our Experience Over 10 Years

Objective

Orbital apex syndrome (OAS) is a rare condition with multiple cranial nerve involvement caused by varied etiologies. It is not only a threat to the patient's vision but also life-threatening due to the intracranial spread of infection, if not diagnosed early and treated accurately. To study the outcome of endoscopic sinus surgery (ESS) for OAS secondary to sinusitis concerning resolution of ptosis, improvement of ophthalmoplegia, visual prognosis, intracranial spread of infection, and mortality.

Methods

A retrospective review of patients with OAS secondary to sinusitis who underwent ESS from 2011 to 2021 was tabulated and analyzed.

Results

Twenty-seven patients (mean age: 55.11+/-16 years; male 62%) were included in this study. At presentation, blurring of vision (81%), headache (66%), diplopia (63%) ptosis (63%) were the most common symptoms, and ophthalmoplegia (100%) was the most common sign. Five patients had no perception of light and the rest had various degrees of vision impairment. The most common etiopathology of sinusitis was fungal sinusitis (12 mucormycosis and four aspergillus). The final visual prognosis at three months follow-up post-ESS showed vision stabilization (no improvement or worsening) in 13 (48%) patients, improvement in seven (26%) patients, and vision deterioration in two (7%) patients. There was a significant improvement in ptosis (70%) and ophthalmoplegia (85%). There was no intracranial spread of infection or recurrence with a mortality rate of 3.7% (one patient).

Conclusion

ESS coupled with appropriate antimicrobials effectively treats OAS secondary to sinusitis with decreased morbidity and mortality.

Clinical Outcomes of Severe Rhinosinusitis Complicated with Cavernous Sinus Syndrome

Background: Various diseases involving the cavernous sinus can cause a condition called cavernous sinus syndrome (CSS), which is characterized by ophthalmoplegia or sensory deficits over the face resulting from the compression effect of internal structure. While tumor compression is the most reported cause of CSS, statistical data on CSS caused by infections are limited. Its risk factors, treatment methods, and clinical outcomes are not well-documented. Methods: In this retrospective study, we reviewed the data of patients admitted to a tertiary medical center from 2015 to 2022 with a diagnosis of acute and chronic sinusitis and at least one diagnostic code for CSS symptoms. We manually reviewed whether patients were involved in two or more of the following cranial nerves (CN): CN III, CN IV, CN V, or CN VI, or at least one of these nerves with a neuroimaging-confirmed lesion in the cavernous sinus. Results: Nine patients were diagnosed with rhinosinusitis-related CSS. The most common comorbidity was type 2 diabetes, and the most common clinical manifestations were diplopia and blurred vision. The sphenoid sinus was the most affected sinus. One patient expired due to a severe brain abscess infection without surgery. The remaining patients underwent functional endoscopic sinus surgery, and 50% of the pathology reports indicated fungal infections. Staphylococcus spp. was the most cultured bacteria, and Amoxycillin/Clavulanate was the most used antibiotic. Only four patients had total recovery during the follow-up one year later. Conclusions: CSS is a rare but serious complication of rhinosinusitis. Patients with diabetes and the elderly may be at a higher risk for this complication. Even after treatment, some patients may still have neurological symptoms.

Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review

The clinical features and prognostic factors of intracranial aspergillosis in immunocompetent patients without risk factors are not well known. PubMed, Scopus, Google Scholar, and Web of Science were searched for all relevant case reports/series on adult patient (≥ 18 years) with aspergillosis published from 1976 to 2018. One hundred eighty-two patients (median age, 40 years; range, 18-83 years; male:female, 115:67) were identified. Types of intracranial aspergillosis included intracranial mass from the skull base (54.9%), pure intraparenchymal disease (23.6%), meningoencephalitis (13.2%), and dural-based mass (8.2%). Vascular complications occurred in 44 patients (26.3%). Eighty-one patients (44.5%) had favourable final clinical outcomes without any deficits, whereas 58 (31.9%) died. Disease-related mortality improved significantly over time (43.1% [28/65] before 2000, 25.9% [30/116] after 2001; p = 0.021). Patients with meningoencephalitis demonstrated the highest mortality rate (79.2%, 19/24). Medical non-responders (patients whose disease course worsened after receiving the initial medication regimen) and vascular complications (the presentation of subarachnoid haemorrhage, intracerebral haemorrhage, or infarction related to the rupture or occlusion of intracranial vessels) were significantly associated with mortality (p < 0.001). Findings from the current review may help predict patient prognosis at the initial assessment and determine potential prognostic factors.

Invasive fungal disease misdiagnosed as tumour in association with orbital apex syndrome

Invasive sino-orbital aspergillosis is a rare cause of orbital apex syndrome (OAS) in immunocompetent patients and often misdiagnosed as tumour because of its aggressive nature and invasive patterns. We report a 23-year-old immunocompetent man presenting with painful progressive loss of vision, ophthalmoplegia and proptosis of the right eye suggestive of OAS. MRI with gadolinium contrast showed an enhancing heterogeneous mass filling the paranasal sinuses, extraconal space and extending up to the right orbital apex. A functional endoscopic biopsy reported as invasive sino-orbital aspergillosis. He was started on intravenous voriconazole and maximal surgical debridement was done. He gradually regained his vision to 20/30 in the right eye. A review of literature reported several such cases which were managed medically or surgically but with poor visual recovery. This case highlights the need for awareness among clinicians for early diagnosis and treatment to prevent vision loss and better survival.

Chronic invasive sinus and intracerebral aspergillosis controlled by combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution

Chronic invasive aspergillosis of the sinus is frequently fatal in the absence of early surgical and chemotherapeutic intervention because of its invasion of vascular tissue. We attempted to control a case of inoperable invasive aspergillosis of the sinus with micafungin and itraconazole oral solution. We prescribed a daily oral dose of 400 mg of itraconazole, which is twice the usual dose, and monitored the serum concentration of the drug. Finally, we were able to control the spread of the lesion. This case indicates that combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution is an alternative treatment strategy for inoperable invasive aspergillosis of the sinus.

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.

Clinical presentation, aetiology and prognosis of orbital apex syndrome

OBJECTIVES

To present the clinical features, determine the causes and evaluate the prognosis of orbital apex syndrome in patients of Songklanagarind Hospital.

METHODS

A retrospective review was conducted of patients diagnosed with orbital apex syndrome between January 1, 2002 and December 31, 2008.

RESULTS

In our series, the major cause of orbital apex syndrome was carotid-cavernous sinus fistula, for which 30 patients were diagnosed. After excluding those patients whose condition was caused by carotid-cavernous sinus fistula, 50 patients (58 eyes) were analyzed. The mean age of the patients was 47.60 ± 18.88 years (27 male patients and 23 female patients). The most common presenting symptom was blurred vision (86%). The median duration of the presenting symptom was 37.5 d. Of the 50 patients the most frequent aetiology of orbital apex syndrome was neoplasia (48%), of which lymphoma was the most common in this group. After treatment, the vision of 19.4% of the patients improved and proptosis improved by 68.4%.

CONCLUSIONS

The most common presenting symptom of orbital apex syndrome was blurred vision. The most frequent aetiology of orbital apex syndrome of all patients was carotid-cavernous sinus fistula, while the next most frequent was neoplasm, of which lymphoma was the most common in this group. Patients had a good outlook, after treatment directed at the cause, with a modest improvement in vision and exophthalmos in more than half of patients.

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 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 intracranial aspergillosis: the management dilemmas

BACKGROUND

Invasive intracranial aspergillosis remains a disease with high morbidity and mortality. The rapid increase in the incidence of this disease led us to review the literature and formulate a treatment protocol for such patients.

METHODS

An analysis of 46 patients with invasive intracranial aspergillosis is presented and the subgroups of extradural and intradural variety are evaluated with different treatment strategies.

RESULTS

Patients with extradural form of disease had 100% survival, whereas antifungal chemotherapy preloading tends to provide a better outcome.

CONCLUSIONS

Extradural aspergillosis does not need chemotherapy preloading, whereas intradural variant may have improved survival chances after preloading. Liposomal formulation has an advantage of shortened time duration for preloading, because the daily administration dose is 6 times higher than conventional preparation.

Invasive Aspergillus terreus sinusitis with orbitocranial extension: case report

BACKGROUND

Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient.

CASE DESCRIPTION

This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month.

CONCLUSION

A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.

Dose finding in aspergillosis

Invasive aspergillosis (IA) continues to represent a significant challenge for physicians in charge of immunocompromised patients. Voriconazole, caspofungin, itraconazole, and the different formulations of amphotericin B (AmB) are all approved for therapy of IA. To collect information on the effect of high dose of antifungals in the treatment of IA, data from the available medical literature were reviewed. For AmB there are no data demonstrating any better clinical activity of doses higher than standard. For liposomal-AmB preliminary data seem to show that high doses are not more efficacious than the standard dose, and it is probably more toxic. Anecdotal data of itraconazole suggest that high dosages might be feasible and it has been associated with good clinical results. Unpublished data about voriconazole suggest the absence of any better activity of high plasma concentrations. For caspofungin the efficacy of higher dosage did not seem to be better than that obtained with the traditional dosage. Prospective studies are required, because many confounding factors may obscure the effects of the higher dosages when data are retrieved retrospectively.

Natural Course of Hematoma in Lateral Rectus Muscle Followed by Magnetic Resonance Imaging

We report a patient with a spontaneous intramuscular hematoma in the lateral rectus muscle of the eye that resolved without medication with maintenance of good vision. A 40-year-old woman presented with ocular pain and exophthalmos in her right eye. She had no history of trauma or surgery. Exophthalmos and limitation of abduction and supraduction of her right eye were present at the initial examination. Magnetic resonance (MR) images showed an intramuscular hematoma in the right lateral rectus muscle. Her other ocular findings were within normal limits. Five months later without any treatments, the MR images were within normal limits, and her ocular signs and symptoms were completely resolved. Careful observations including MR imaging is sufficient for patients with a spontaneous intramuscular hemorrhage in the extraocular muscle, and the visual prognosis is good.

Beneficial Effect of Methylprednisolone on Cardiac Myocytes in a Rat Model of Severe Brain Injury

Cardiac injury, occurred after traumatic brain injury (TBI), has been recognized for more than a century. Bcl-2 is a key regulatory component of the mitochondrial cell death pathway, and its overexpression is cytoprotective in many cell types. The therapeutic agents, which induce the expression of bcl-2 protein, might provide a new therapy to prevent cardiac myocyte damage following TBI. In this study, we investigated whether methylprednisolone sodium succinate (MPSS) influences the expression of bcl-2 in the heart. Wistar-Albino female rats underwent TBI (300 g/cm) generated by the weight-drop method, and were left untreated (n = 6) or treated with either MPSS (30 mg/kg) (n = 6) or vehicle (albumin solution) (n = 6). The heart was isolated from each animal with TBI. For comparison, the hearts were isolated from sham-operated (n = 6) and control rats (n = 6). The relative expression of bcl-2 mRNA in the heart was quantitated by real-time polymerase chain reaction. We also assessed lipid peroxidation in the heart tissue by determining the concentration of thiobarbituric acid-reactive substances (TBARs) as an indicator of tissue damage. The bcl-2 expression level was significantly higher in the hearts of MPSS-treated rats compared to that of other TBI groups (p < 0.0001). Moreover, TBI increased the lipid peroxidation in the heart, which was significantly reduced by the treatment with MPSS (p < 0.0001). These findings provide evidence for the efficacy of MPSS in protection of cardiac myocytes to achieve optimal heart donation after TBI in heart transplantation.