Invasive aspergillus sinusitis with orbitocranial extension

Acute invasive fungal rhinosinusitis in post-COVID-19 patients in Vietnam

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a potentially lethal infection commonly found in immunocompromised patients. It is considered the most aggressive subtype of fungal sinusitis and can lead to severe morbidity and mortality. There was a significant increase in the incidence of AIFR in post-COVID-19 patients compared to AIFR cases before the COVID-19 pandemic. This study aimed to describe the clinical presentation of AIFR associated with COVID-19 illness.

METHODS

A retrospective study included 22 patients diagnosed with AIFR with a recent COVID-19 infection.

RESULTS

The most frequent disease associated with AIFR was diabetes mellitus (95.5%). The mycological analysis identified infection caused by Aspergillus species in 72.7% of patients. Along with stabilizing hemodynamic parameters and controlling any comorbidities, all patients in the present study underwent combined surgical debridement followed by antifungal medications. The overall survival rate was 72.7%. The chance of developing a fatal outcome was significantly higher if meningitis presented initially (odds ratio 35.63, p < 0.05).

CONCLUSION

The presence of meningitis upon initial diagnosis is related to a significantly higher chance of developing a fatal outcome and should be considered, especially in AIFR patients previously treated for COVID-19 infections. Early diagnosis, early use of antifungal agents, aggressive surgical debridement, and control of comorbid conditions remain crucial in managing AIFR.

LEVEL OF EVIDENCE: 4

Non-Mucormycetes Causes of Fungal Rhino Sinusitis With Periocular Swelling in COVID-19 With Delta Variant

Objective: To highlight fungi other than mucormycetes as causative agents of rhinosinusitis with periocular swelling in coronavirus (COVID-19) infection caused by Delta variant of SARS-CoV-2 virus and identify the presenting features, risk factors, intervention, and outcomes.

Methods and analysis: A retrospective interventional study of 96 patients with fungal rhinosinusitis and periocular swelling was done in patients with concurrent or recovered COVID-19 infection with the Delta variant (B.1.617.2) of SARS-CoV-2 virus in India. All patients with mucormycetes infection were excluded. Clinical presentation, medical history, blood reports, and imaging were analyzed. Management was by intravenous (IV) liposomal amphotericin B and functional endoscopic sinus surgery (FESS) with paranasal sinus debridement. Limited orbital debridement with or without transcutaneous retrobulbar liposomal amphotericin B (TRAMB) was done in patients with orbital involvement. Postoperative antifungal therapy was decided on the basis of the causative fungi.

Results: Four cases of Aspergillus and one each of Fusarium, Curvularia, and Penicillium-associated fungal rhinosinusitis with periocular swelling were seen. Signs of orbital involvement on MRI were present in all four of them. Two of these showed partial third-nerve palsy while one case with aspergillosis suffered cavernous sinus thrombosis. Proptosis was not witnessed in any case. History of diabetes and use of steroids was seen in all patients. All patients had mild to moderate COVID-19 with oxygen supplementation needed in one. No mortality, acute vision loss, or exenteration took place.

Conclusion: Aspergillus, Fusarium, Curvularia, and Penicillium were non-mucormycetes causes of fungal rhinosinusitis with periocular swelling in COVID-19 infection with the Delta variant (B.1.617.2) of SARS COV-2 virus. Few cases showed orbital and intracranial involvement.

A Case of Invasive Aspergillus Rhinosinusitis Presenting with Unilateral Visual Loss and Subsequently Associated with Meningitis, Subarachnoid Hemorrhage, and Cerebral Infarction

Visual impairment can occur because of several mechanisms, including optic nerve disease and occasionally fungal sinusitis. An 87-year-old man presented with the loss of right visual acuity; he was diagnosed with optic neuritis. Steroid pulse therapy was not effective. One month later, he became unconscious because of meningitis, following which treatment with ceftriaxone and acyclovir was initiated. However, his consciousness deteriorated because of a subarachnoid hemorrhage caused by a ruptured aneurysm. Meningitis and vascular invasion caused by fungal rhinosinusitis were suspected, and the sinus mucosa was biopsied. He was pathologically diagnosed with invasive Aspergillus rhinosinusitis. Despite continuous liposomal amphotericin B administration, he died of cerebral infarction, following a right internal carotid artery occlusion. It is important to consider the possibility of Aspergillus as an etiological agent, especially when cerebrovascular events are associated with visual impairment.

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.

A treated case of rhinocerebral zygomycosis with aspergillosis: a case report from India

Zygomycosis and aspergillosis are two serious fungal infections that are commonly seen in immunocompromised patients. Since both of these infections involve fungi that invade vessels of the arterial system, an early and rapid diagnosis by direct examination of KOH mounts of the relevant clinical sample can clinch the diagnosis. Here, we present a case of a 60-year-old diabetic patient who presented with swelling and pain over the nose and left eye for 7 days with loss of vision in the left eye. After investigation, the patient was diagnosed as having rhinocerebral mucormycosis and aspergillosis, and was initially treated with amphotericin B (1 mg kg^-1 day^-1 intravenously), followed by endoscopic debridement under general anaesthesia. The patient gradually improved after surgery, and treatment with intravenous amphotericin B was continued along with the addition of 200 mg oral voriconazole twice daily (for the aspergillosis). With prompt diagnosis and treatment, the patient survived these fatal fungal co-infections and finally was discharged.

Special scenarios in the management of central nervous system aspergillosis: a case series and review of literature

Aspergillus is a rare but important opportunistic pathogen to invade the central nervous system (CNS). It is a significant pathogen of not only immunocompromised but also immunocompetent patients. Its manifestations are pleiotropic, reflecting multiple mechanisms of pathogenesis and host interactions. Despite significant advances in diagnostic methods and therapeutic options, the mortality remains high. Several advances have been made in medications and surgical management, yet, current treatment practices lack uniformity. Patient woes are further heightened by the high costs of treatment and prolonged duration of therapy. In view of the challenging aspects of this disease, we present a short review of four challenging cases touching on the varied aspects of management of CNS aspergillosis covering pathogenesis, diagnostic pitfalls, surgical and medical options and evidence-based guidelines for the management of the same.

Fatal case of cerebral aspergilloma complicated by ventriculitis and bacteremia due to Salmonella species in a sickle cell disease patient

To describe a fatal case of invasive Aspergillus flavus sinusitis in a 43-year old female with sickle cell disease (SCD) complicated by intracerebral aspergilloma and invasive Salmonella infection. Cerebral aspergilloma carries a very high mortality rate. The patient developed post-craniotomy intracerebral hemorrhage at the site of biopsy, Salmonella species sepsis and ventriculitis. She presented with a 2-month history of headache, dizziness, personality and behavioral changes, and vomiting. Initial clinical evaluation raised the suspicion of brain tumor. Brain magnetic resonance imaging revealed a left frontal, thick-walled ring-enhancing lesion with extensive surrounding edema suggestive of a neoplastic lesion, or a contiguous inflammatory or infectious process from the skull base. Despite early diagnosis and appropriate antifungal and surgical management, she eventually died from severe infection and respiratory arrest. In conclusion, invasive aspergillosis should be included in the differential diagnosis of SCD patients with central nervous system (CNS) lesions.