[Cavernostomy for Extensive Intrapulmonary Cavitary Abscesses That Turned into Destroyed Lungs]

Surgical resection of the infected lung with curative intent is the treatment of choice for lung abscesses that are difficult to control with medical treatment alone. However, lung resection is considered difficult in some cases. Herein, we report two cases of destroyed lungs with severe symptoms, for which palliative cavernostomy was performed instead of infected lung resection. Case 1 was a 45-year-old man who had granulomatosis with polyangiitis in both lungs. Steroid pulse and immunosuppression therapies were repeated, resulting in a huge, destroyed lung on the right side with chronic necrotizing bilateral aspergillosis, causing severe symptoms. Considering the bilateral spread and extension of the cavity lesions, cavernostomy was performed for the destroyed right lung. Case 2 was a 73-year-old woman who had undergone a left lower lobectomy for a metastatic lung tumor and developed a destroyed lung with severe symptoms in the residual left upper lobe caused by a non-tuberculous mycobacterial infection. Since a completion pneumonectomy with curative intent was considered too invasive for her poor general condition, cavernostomy was performed for the destroyed lung. Palliative operations significantly relieved the severe symptoms and improved the general conditions of these patients, enabling outpatient follow up.

Orbital Apex Syndrome Caused by Intraorbital Aspergillus Infection

Orbital apex syndrome, a clinical disease that is uncommon and has a high fatality rate. Tumor, endocrine, and inflammatory variables are frequently responsible for its occurrence. The authors describe a 53-year-old Chinese man who was diagnosed with orbital apex syndrome and coupled type 2 diabetes mellitus and a fungus infestation. Treatment included nasal endoscopic orbital apical decompression, anti-infection, and adequate debridement. Except for inevitable optic nerve damage, postoperative proptosis and headache manifestations improved, and systemic infection was timely contained with no signs of recurrence or serious complications occurred. The orbital apex syndrome is difficult to treat, and soon as possible biopsy of the lesion, aggressive surgical decompression, and antifungal treatment seem to be effective ways to improve survival rates.

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Combined Endonasal-Transorbital Approach to Manage the Far Lateral Frontal Sinus: Surgical Technique

In recent decades, the ever-expanding use of endoscopes and development of dedicated instrumentation have reshaped the panorama of surgical approaches to the frontal sinus.¹ Nonetheless, the far lateral portion of the sinus might still represent a concern, especially in cases with unfavorable or distorted anatomy.^2,3 We report the case of a 52-year-old man, referred to our department for recurrent episodes of left orbital swelling and supraorbital headache, 3 months after Draf III frontal sinusotomy for marsupialization of multiple frontal mucoceles. Computed tomography and magnetic resonance imaging scans were consistent with persistent inflammatory tissue in the far lateral left frontal sinus. Revision surgery was performed, adopting a combined endonasal orbital transposition³ and superior eyelid transorbital approach.^4,5 The postoperative course was uneventful, and the microbiologic and histologic examinations demonstrated noninvasive Aspergillus fumigatus infection. The radiologic control showed patency of the frontal recess and complete clearance of the sinus. The patient is asymptomatic after 16 months (Video 1). The transorbital approach is effective in managing orbital and frontal sinus diseases,⁶ and the combination with the endonasal route grants complete access to the frontal sinus, even in cases of high pneumatization and lateral extension.^4,7 Multiportal transorbital approaches represent additional techniques in the rhinologist's surgical armamentarium, which can overcome the limits of a single port approach.^8,9 Reports on their use providing technical hints and critical considerations are to be encouraged to ease and stimulate the surgical training in this field.

Maxillary fungus ball in a diabetic patient. An odontogenic origin

INTRODUCTION

Fungus ball (FB) represents a granulomatous mass due to a fungal colonization which may disseminate and potentially lead to a systemic infection. Maxillary fungus ball is considered to be a complication of dental treatment and, according to relevant literature, it often stems from improper endodontic therapies.

MATERIAL AND METHODS

The authors report the case of a 69-year-old caucasian woman with nasal respiratory distress and frequent sinusitis symptoms. According to clinical and radiological evidence, FESS surgery was planned, thus validating FB diagnostic hypothesis.

CONCLUSIONS

Fungal infection should always be considered in patients with sinusitis and previous root canal theraphy. Misdiagnosis can lead to severe complications. Surgical removal seems to be effective and resolutive.

KEY WORDS

Endoscopic surgery, Fungus Ball, Maxillary sinusitiss.

Orbital apex syndrome secondary to aspergilloma masquerading as a paranasal sinus tumor: A case report and literature review

RATIONALE

Orbital apex syndrome is a complex clinical disorder featuring a collection of cranial nerve deficits characterized by impairment of the extraocular muscles, the ophthalmic branch of the trigeminal nerve, and even the optic nerve. Sino-orbital aspergillosis is rare but aggressive infection. Surgical resection accompanied by antifungal medication is advised currently.

PATIENT CONCERNS

We report a 61-year-old woman diagnosed as aspergilloma presenting with the characteristic manifestations and imaging features of orbital apex syndrome.

DIAGNOSES

Paranasal sinus tumor was misdiagnosed initially according to magnetic resonance imaging of the orbit. Finally aspergilloma was diagnosed by pathologic report.

INTERVENTIONS

The anti-fungal medication, voriconazole, was administered immediately. Surgical excision was also done due to the poor response to medical treatment.

OUTCOMES

Postoperative follow-up showed no recurrence of aspergillosis but the vision was lost permanently.

LESSONS

Invasive sino-orbital aspergillosis as an aggressive disease with highly invasive patterns and it may be misdiagnosed as tumors. To achieve better prognosis and survival, clinicians should be aware of this distinct manifestation.

Aspergillus myofasciitis in a chronic granulomatous disease patient: first case report

Aspergillus myofasciitis is a rare infection of the muscles and their fascial sheaths that has been reported in patients with immune deficiencies of various kinds but, until now, not with chronic granulomatous disease (CGD). Patients affected by CGD are at high risk of invasive aspergillus infections. The case described involves a 14-year-old boy with a severe autosomal recessive CGD who was admitted to hospital with an Aspergillus myofasciitis of the left forearm. He was treated with liposomal amphotericin for 14 days and then with oral voriconazole for three months with an excellent clinical outcome. He did not evidence any recurrence in the following 30 months using itraconazole prophylaxis.

Fungal Endocarditis Due to Aspergillus oryzae: The First Case Reported in the Literature

Infective endocarditis (IE) is a severe disease with high mortality and morbidity. Prosthetic valve endocarditis is a life-threatening complication which can occur in less than 10% of patients with valve prosthesis. A fungal etiology of IE is rare and accounts for only 2-4% of all case of endocarditis, but is associated with a higher mortality and morbidity. Herein is reported the first case of fungal endocarditis of aortic valve prosthesis due to Aspergillus oryzae in a 67-year-old caucasian man who nine years previously underwent mitral and aortic valve replacement with mechanical prostheses, and tricuspid annuloplasty for acute IE due to Enterococcus spp. Seven months previously, the patient also underwent a redo cardiac procedure to replace a mitral valve prosthesis with a new mechanical device due to a leakage. Aspergillus oryzae showed impressive growth with strong and unexpected virulence in both local and systemic settings.

Ventricular pneumocephalus, cervical subarachnoid pneumorrhachis, and meningoencephalitis in a dog following rhinotomy for chronic fungal rhinitis

CASE DESCRIPTION

A 5-year-old 35.8-kg (78.8-lb) neutered male Labrador Retriever was evaluated for chronic nasal discharge associated with a fungal infection. The dog had previously been prescribed antimicrobials and antifungal treatment, but owner compliance was lacking.

CLINICAL FINDINGS

Bilateral mucopurulent nasal discharge, mild ulceration of the left nasal commissure, and hyperkeratosis of the dorsal nasal planum were present. Computed tomography revealed destruction of the intranasal structures, focal lysis of the cribriform plate, and invasion of a soft-tissue mass into the frontal cortex. Rhinoscopy revealed a large pale mass in the caudal aspect of the right nasal passage; a biopsy sample was consistent with Aspergillus sp on histologic evaluation.

TREATMENT AND OUTCOME

Initial treatment included medical management with an antifungal agent. Approximately 3 months later, a large fungal granuloma in the right frontal sinus was removed and debridement was performed via dorsal rhinotomy. One month after surgery, the dog was evaluated for signs of cervical pain and altered mentation. An MRI and CSF analysis were performed; diagnoses of ventricular pneumocephalus, subarachnoid pneumorrhachis, and meningoencephalitis were made. Management included oxygen therapy and administration of antimicrobials, analgesics, and antifungal medications. On follow-up 9 months after initial evaluation, neurologic deficits were reportedly resolved, and the dog was doing well.

CONCLUSIONS AND CLINICAL RELEVANCE

This report emphasizes the importance of prompt, appropriate treatment of fungal rhinitis in dogs. Although rare, pneumocephalus and pneumorrhachis should be included as differential diagnoses for neurologic signs following treatment for this condition. In this dog, the complications were not considered severe and improved over time with supportive care.

Analysis of Surgical Treatment for Pulmonary Aspergilloma

Surgery for pulmonary aspergilloma is reputed to be risky. The results of surgical treatment of pulmonary aspergilloma in 41 patients between 1988 and 2003 were evaluated retrospectively. Hemoptysis occurred in 31 patients (75.6%) and it was massive (> 300 mL in 24 hr) in 3. The underlying lung disease was tuberculosis in 35, bullous lung disease in 2, hydatid cyst in 2, and lung carcinoma in 2 patients. Lobectomy, bilobectomy, wedge resection, and pneumonectomy were performed in 27, 4, 6, and 4 patients respectively. The postoperative complication rate was 24.4%. One patient, who had a right pneumonectomy, died due to respiratory failure; the mortality rate was 2.4%. Recurrent hemoptysis was observed in only one patient. Early surgical treatment of patients with pulmonary aspergilloma resulted in a satisfactory outcome with acceptable morbidity, low mortality, and effective prevention of recurrent hemoptysis. Pneumonectomy has a high morbidity, thus it should be avoided if possible.

Surgical Management of Pulmonary Aspergilloma

Records of 59 patients (41 males and 18 females) who underwent 70 operations for pulmonary aspergilloma in a 23-year period were examined retrospectively. Sixty-three operations were for primary treatment of pulmonary aspergilloma, and 7 were for complications of surgery. Twenty-six postoperative complications occurred in 19 patients. Three lobectomies that resulted in bronchopleural fistula were managed by intercostal muscle-flap closure and partial thoracomyoplasty. Two patients died within the first week of surgery. Surgery is the treatment of choice for most patients with pulmonary aspergilloma. Selective bronchial artery embolization is helpful only in combating hemoptysis, and this has been considered a temporary measure in most reports. Thus, open thoracotomy and anatomical resection are recommended as early as possible after the diagnosis is established.

Invasive Primary Colonic Aspergillosis in the Immunocompetent Host without Classical Risk Factors

Invasive aspergillosis (IA), generally considered an opportunistic infection in immunocompromised hosts, is associated with high morbidity and mortality. IA commonly occurs in the respiratory tract with isolated reports of aspergillosis infection in the nasal sinuses, central nervous system, skin, liver, and urinary tract. Extra-pulmonary aspergillosis is usually observed in disseminated disease. To date, there are a few studies regarding primary and disseminated gastrointestinal (GI) aspergillosis in immunocompromised hosts. Only a few cases of primary GI aspergillosis in non-immunocompromised hosts have been reported; of these, almost all of them involved the upper GI tract. We describe a very rare case of IA involving the lower GI tract in the patient without classical risk factors that presented as multiple colon perforations and was successfully treated by surgery and antifungal treatment. We also review related literature and discuss the characteristics and risk factors of IA in the immunocompetent hosts without classical risk factors. This case that shows IA should be considered in critically ill patients, and that primary lower GI aspergillosis may also occur in the immunocompetent hosts without classical risk factors.

Septic arthritis of the temporomandibular joint caused by Aspergillus flavus infection as a complication of otitis externa

Septic arthritis of the temporomandibular joint (TMJ) is a very rare complication of otitis externa that can lead to ankylosis and destruction of the joint. We report the case of a 74-year-old man who developed aspergillosis of the TMJ following otitis externa. To the best of our knowledge, this is the first reported case of TMJ septic arthritis secondary to otitis externa caused by Aspergillus flavus. The patient was successfully managed with condylectomy, debridement, and drug treatment with voriconazole.

[Pulmonary aspergilloma surgery: a mono-institutional experience]

INTRODUCTION

Pulmonary aspergiloma or mycetoma is a saprophytic colonization of a preexisting cavity by aspergilloma. Surgical resection is the only effective long-term treatment, but remains controversial because of the high rate of complications in the perioperative and postoperative time.

OBJECTIVES

Analysis of the experience of a Cardiothoracic Surgery Center for the treatment of pulmonary aspergilloma and evaluation of the prognostic factors after surgery.

MATERIAL AND METHODS

Retrospective analysis including all the patients with a diagnosis of pulmonary aspergilloma submitted to surgery for a 10 years period, in a single institution (June 2001-June 2011).

RESULTS

The study included 22 patients (18 men) with a mean age of 51.0 + 17.4 years. Of them, 46% were smokers, 41% were alcoholic and 50% had a previous history of tuberculosis. Most of the patients had a complex aspergilloma (73%) and 17% a simple aspergilloma. The most common presentation was hemoptysis (50%). The common surgical procedure performed was atypical lung resection in 55%, lobectomy in 27% and pneumectomy in 9%. Two patients were submitted to thoracoplasty. There was one operative death (5%). Postoperative complications occurred in 36% and the most frequent were pneumothorax (18%) and empyema (18%). The mean follow-up period was 52 months (3 - 116) and the 5 years mortality rate of 35%. Of them, 4 patients died because of non-related causes and 3 were immunosuppressed patients. The mortality was 40% in the group of complex aspergilloma and 33% in the group of complex aspergilloma.

DISCUSSION

The most common surgical procedure performed was atypical lung resection. The postoperative complications rate was similar to previous studies.

CONCLUSION

Surgical resection of aspergilloma presents a low morbidity and mortality. Therefore, for patients with lung function preserved, it is the preferred treatment.

[A case of cavernous sinus aspergillosis]

We reported a case of cavernous sinus aspergillosis. A 62-year-old man complained of trigeminal neuralgia in the right V1 region. Neurological examination on admission showed ptosis, loss of light reflex and ophthalmoplegia externa in the right side. MRI enhanced with gadolinium demonstrated sphenoid sinusitis and mass lesion in the right cavernous sinus. MRA revealed right internal carotid artery occlusion. An open biopsy using the extradural temporopolar approach was performed. Pus discharge was observed from the cavernous sinus and histological examination showed hypha of Aspergillus. With early voriconazole treatment, the patient had improvement in headache, ptosis and ophthalmoplegia externa. Cavernous sinus aspergillosis is often found after sphenoiditis. It results in invasion to an internal carotid artery and worsens the patient's prognosis by cerebral infarction, so early diagnosis and treatment are important. We should consider aspergillosis as one of the differential diagnoses of a mass in the cavernous sinus. The epidural approach to this lesion was available to obviate aspergillus dissemination into the medullary cavity.

Surgical treatment options for maxillary sinus fungus balls

OBJECTIVE

1) To evaluate the effectiveness and side-effects of endoscopic surgical treatment for maxillary sinus fungus balls, and to describe approaches to limiting recurrence of the disease and surgical complications. 2) To compare the results of this nasal endoscopic treatment with the results of treatment using a vestibular approach to the anterior wall of the maxillary sinus as described in the literature.

PATIENTS AND METHODS

An institutional retrospective review was conducted for patients undergoing treatment for a maxillary sinus fungus ball using endonasal surgery alone from January 2005 to December 2010.

RESULTS

A total of 100 patients were included in the study (58 women and 42 men, average age 54 years). The median follow-up time was 32 months. Three patients had a recurrence after our team performed endonasal surgery. No patients experienced complications.

CONCLUSION

Our results are consistent with previous findings, indicating that the postoperative complication rate for endonasal surgery is low by comparison with the vestibular approach. Both techniques have similar outcomes. The nasal endoscopic route offers similar rates of success with a negligible complication rate.

Invasive Aspergillus infection localized to the gastric wall: report of a case

Invasive aspergillosis is most commonly seen in patients with immune disorders and usually in the lung. Local invasive aspergillosis of the gastrointestinal system is quite rare. A 13-year-old female without immune deficiency presented with acute abdomen due to full-thickness necrosis of the gastric fundus. The necrotic gastric wall was excised and the stomach repaired. The pathology revealed a gastric ulcer with invading Aspergillus hyphae and spores. Aspergillosis is an opportunistic infection and its spores cannot survive in the normal gastric mucosa. The Aspergillus spores in this case probably grew on a background of gastric ulcer and caused wall necrosis and that the surgical treatment possibly provided a cure because it remained localized to the gastric wall.

Emergency hemicolectomy for intestinal primary aspergillosis in acute myeloid leukemia

Intestinal aspergillosis is an infection with a very high death rate especially in leukemic patients. Here we describe a case of a 46 years old woman with acute myeloid leukemia (LAM M5) who developed intestinal primary aspergillosis. This patient was diagnosed with LAM M5 through bone marrow aspiration and bone biopsy in March 2004. Symptoms of the disease were slight persistent fever, weight loss, asthenia, anemia, thrombocytopenia,and leukocytosis with high number of blasts in peripheral blood. After induction chemotherapy with ICE (Ifosfamide, Carboplatin, Etoposide), she developed neutropenia and high fever without apparent infective foci. She was treated with empiric antibiotic therapy, nevertheless she developed an intense diarrhea and ileo-cecal distention. Diagnostic exams didn't show signs of a focal lesion. Despite the change in antibiotic treatment and the transfusions of granulocytes and blood cells, the patient developed extremely critical conditions with persistence of neutropenia and abdominal distention. A surgical treatment was decided at the time. We treated the patient with a two steps surgical procedure. The first step was a right abdominal ileostomy followed by improvement of general conditions and then the second step a right colectomy. The histological morphology confirmed necrotizing colitis with Aspergillus ife. At that time , treatment with voriconazole was started. The general conditions of the patient improved rapidly and we were able to treat the patient with other medical anti-leukemic therapies. The patient is now cured and in healthy state. We obtained a good clinical result as only in other few cases described in literature.

[Unilateral frontal sinus aspergillosis: the combined endoscopic and mini-trephination approach]

OBJECTIVE

Aspergillosis is a common fungal infection of the paranasal sinuses. Localization in the frontal sinus is usually secondary to involvement of one of the other sinuses. Isolated frontal sinus aspergillosis is rare and only 5 cases are described in literature.

CLINICAL CASE

We report a case of a patient with a frontal sinus aspergilloma associated with ipsilateral chronic ethmoidal and maxillary sinusitis, successfully treated with a combined endoscopic and mini-trephination approach "Lemoyne technique".

DISCUSSION AND CONCLUSION

The endoscopic approach to the frontal sinus is considered the best way to deal with frontal sinus aspergilloma, but it is sometimes not sufficient to guarantee the complete removal of the fungus ball. In such cases a mini-trephination of the frontal sinus with associated irrigation provides a more accurate visualization and toilette of the sinus.

[Fatal sino-orbital aspergillosis in an immunocompetent case]

The paranasal sinus infections caused by Aspergillus spp. are usually presented clinically with mild symptoms, however they may lead to invasive disease and mortality especially in immunocompromised individuals. In this report a fatal case of sino-orbital aspergillosis developed in an immunocompetent patient has been presented. Seventy-four years old female patient was admitted to the hospital with the complaints of fever and progressively increasing headache that continued for 15 days. Due to the development of nausea, vomiting, loss of consciousness and stiff neck in the following days, cerebrospinal fluid (CSF) sample was obtained. Direct microscopic examination of the Gram and acidfast staining of the CSF sample revealed no microorganisms, no growth was detected in CSF culture and PCR amplification was negative for Herpes simplex virus and Mycobacterium tuberculosis. Since no response was achieved by empirical ceftriaxone, ampicillin and conventional anti-tuberculosis treatment and tachypnea, proptosis and progressive respiratory failure developed in the patient, she was transferred to the intensive care unit. The radiological examination revealed soft tissue lesion filling the sphenoid sinus, extending to the nasal cavity and suprasellar cistern, destruction of bones, dilated orbital vein, cavernous sinus thrombosis and infarction on left cerebral peduncule. Patient was operated and pus and fungus ball were aspirated from the openings of both sphenoid sinuses. Gomori methenamine silver, periodic acid-Schiff and haematoxylin-eosine staining of the operational material exhibited dichotomously branching hyphae. The patient was diagnosed as invasive sino-orbital aspergillosis based on the clinical, radiological and histopathological findings. Despite antifungal therapy and surgical debridement, the patient died. It should always be kept in mind that aspergillosis can develop in immuncompetent individuals. Delay in diagnosis and treatment may lead to fatality. Thus multidiciplinary approach is necessary for early diagnosis and successful treatment of aspergillus infections.

Aspergillus endocarditis: a review of the literature

We present a case of cardiac device-related Aspergillus endocarditis in a patient with a pacemaker and an allogeneic bone marrow transplant to segue into a review of the Aspergillus endocarditis literature. Aspergillus endocarditis should be suspected in patients with underlying immunosuppression, negative cultures, and a vegetation on echocardiography. Diagnosis ultimately requires confirmation by tissue histology and culture. The optimal treatment approach often requires aggressive surgical debridement in conjunction with prolonged antifungal therapy.

[Treatment of fungal keratitis by penetrating keratoplasty]

BACKGROUND

Fungal keratitis is basically treated by medications. Several cases of fungal keratitis were reported around the world to have been treated successfully by corneal graft--penetrating keratoplasty (PKP). Studies have shown that PKP is a useful treatment, preserves eye globe integrity, and rehabilitates vision in patients with advanced fungal keratitis.

AIM

To study the use of penetrating keratoplasty for the treatment of severe fungal keratitis that could not be cured by antifungal medication.

METHODS

The authors conducted a retrospective analysis of all cases (five cases) of severe fungal keratitis treated and followed-up at the Department of Ophthalmology, Soroka University Medical Center during 2007 and 2008, in which therapeutic PKP was performed. There were one male and 4 females. The age range was between 27 and 78 years. The follow-up period ranged from 4 to 15 months.

RESULTS

Corneal graft remained clear during follow-up in most patients. There was no recurrence of fungal infection and the visual acuity ranged from counting fingers (FC) from 50 cm to 6/36. Complications in some patients included graft rejection in one patient with re-graft which remained clear during follow-up period of 6 months, another patient had a minimal partial graft rejection and incipient cataract which didn't necessitate further intervention.

DISCUSSION AND CONCLUSIONS

PKP is an effective treatment for fungal keratitis that does not respond to antifungal medication. Early surgical intervention before deterioration is recommended.

Efficacy of intrasinusal administration of bifonazole cream alone or in combination with enilconazole irrigation in canine sino-nasal aspergillosis: 17 cases

This study evaluated the effect of 1% bifonazole cream in the treatment of canine sino-nasal aspergillosis (SNA). The cream was instilled through perendoscopically placed catheters into the frontal sinuses and was used either as single therapy after debridement (DC) or as adjunctive therapy after 2% enilconazole infusion (DEC). Twelve dogs were treated initially with DEC: 7 and 3 of these dogs were free of disease after 1 and 2 procedures, respectively, while 2 dogs were cured after DC was used as a second procedure. Five dogs were treated with DC only: in 3 dogs with moderate disease, cure was obtained after a single procedure while, in 2 debilitated patients, cure could not be confirmed. Topical administration of 1% bifonazole cream appears as an effective therapy in SNA, either as an adjunctive therapy to enilconazole infusion or as sole therapy in moderately affected patients.

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.

Surgical resection for successful treatment of invasive pulmonary aspergillosis: Report of 3 cases

We present 3 patients, 2 with recent heart transplants, complicated with invasive pulmonary aspergillosis (IPA), treated successfully with surgical resection. These patients demonstrate the role of surgery in management of IPA, and 2 heart transplant patients are of particular interest as surgical treatment of IPA after solid organ transplantation is seldom reported.

Aspergillus endophthalmitis in orthotopic liver transplantation

In this report, we describe a patient with drug-induced liver failure who developed endogenous endophthalmitis after liver transplantation. Our patient's clinical course was so fulminant that the eye was lost in less than 1 month, without any response to therapy. Recognition of this infection is important because many patients die of disseminated Aspergillus infection, which may be detected early with bedside funduscopic examination by an ophthalmologist. Probably if the patient had referred to us earlier, it may have been possible to save the eye.

Management of allergic fungal sinusitis with postoperative oral and nasal steroids: a controlled study

In patients with allergic fungal sinusitis, the mainstay of treatment remains surgical removal of allergic mucin and fungal debris. But as a single modality, surgery is associated with high rates of recurrence, so a number of adjunctive medical modalities have been tried, including postoperative corticosteroid therapy. We conducted a study of 63 patients with allergic fungal sinusitis who underwent endoscopic sinus surgery with or without postoperative steroid therapy. A group of 30 patients who had been treated prior to January 2000 had undergone surgery only; their cases were reviewed retrospectively, and they served as historical controls. Another 33 patients who were treated after June 2000 underwent surgery plus oral and nasal steroid therapy. All patients were followed for a minimum of 2 years. Recurrences were seen in 50.0% (15/30) of the no-steroid group and 15.2% (5/33) of the steroid group-a statistically significant difference (p = 0.008). The results of our study strongly support the use of steroids to control allergic fungal sinusitis and prevent its recurrence, and we recommend further study to identify the optimal dosage and duration of therapy.

Aspergillus vertebral osteomyelitis and epidural abscess

We present the first reported case of Aspergillus vertebral osteomyelitis and epidural abscess in Singapore in a 50-year-old man with post-tuberculous bronchiectasis. The patient presented with acute urinary retention and flaccid paraplegia. Despite surgical debridement and treatment with voriconazole, the patient developed multiorgan failure and died two weeks after presentation. Early diagnosis and prompt initiation of treatment are emphasised in the hope of improving the outcome of this aggressive condition.

Invasive aspergillosis in paediatric oncology patients

Invasive aspergillosis predominantly occurs in immunocompromised patients and is often resistant to different therapeutically strategies. However, mortality significantly increases if the central nervous system is affected. In this report we describe two cases of invasive aspergilosis, one with kidney involvement with a successful treatment while the other with pulmonary and cerebral involvement with a grave outcome.

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.

Spinal osteomyelitis due to Aspergillus flavus in a child: a rare complication after haematopoietic stem cell transplantation

We report the case of a child affected by acute myeloid leukaemia who was treated with allogeneic haematopoietic stem cell transplantation and developed cervicothoracic spinal osteomyelitis due to Aspergillus flavus. The diagnosis was difficult on a clinical basis, but made possible by conventional radiography and MRI.

[Endovascular management of a left subclavian artery lesion following thoracoplasty for bronchopleural fistula and empyema secondary to aspergillus fumigatus]

Massive and/or recurrent hemoptysis is a clear indication for surgical treatment of pleuropulmonary aspergilloma, despite the incidence of postoperative morbidity and mortality. Thoracoplasty has been widely used for 20 years and is still indicated in these cases, following lobectomy, even though the procedure is not free of complications. We report the case of a patient who required thoracoplasty to treat a pleuropulmonary aspergilloma invading the chest wall. Subsequent placement of an aortic stent-graft was required due to tearing of the left subclavian artery.