Intracranial fungal granuloma: analysis of 40 patients and review of the literature

OBJECTIVE

To describe the characteristics of patients diagnosed with intracranial fungal granuloma (IFG) in the largest reported series to date (to our knowledge).

METHODS

A 22-year retrospective, multi-institutional review of 40 patients, aged 16 to 62 years (mean, 40.2 years), was performed in patients with histopathologically confirmed IFG. The variables were symptoms/signs at presentation, predisposing factors, location of granuloma, involvement of paranasal sinuses, diagnostic studies including blood and urine cultures, surgical procedures performed, specific organism identified, treatment, and prognosis. Plain x-rays, computed tomography, and/or magnetic resonance imaging scans were performed.

RESULTS

Predominant symptoms included headache (83%), vomiting (65%), proptosis (48%), and visual disturbances (48%). Other symptoms were fever, nasal congestion, and seizures (7 [18%]). Common signs included papilledema (12 [30%]), with cranial neuropathy (I, III/IV/VI, and V in 4, 7, and 2 patients, respectively), hemiparesis (3), and meningismus (3). Predisposing factors were diabetes (16 [40%]), tuberculosis (7 [18%]), and immunocompromise related to renal transplant (2), non-Hodgkin's lymphoma (1), and human immunodeficiency virus (1). Location was primarily frontal (10 [25%]), with anterior cranial fossa involved in 8 (20%) patients; 6 (15%) patients had sellar/parasellar involvement. Eighteen (40%) had paranasal sinus involvement. Twenty-nine patients underwent craniotomy for resection, with 11 undergoing biopsy (of which 3 were transsphenoidally approached). Histopathology revealed aspergilloma (25 [63%]), mucormycosis (7 [18%]), cryptococcoma (3), cladosporidium (3), Bipolaris hawaiiensis (1), and Candida species(1). Microbiological analysis of the specimen was positive in 28 (60%) patients. All patients were treated with amphotericin B, fluconazole, and/or flucytosine. Only 26 patients completed amphotericin B therapy (due to nephrotoxicity). Mortality was 63%, most commonly due to meningoencephalitis (16 [36%]).

CONCLUSIONS

High index of suspicion of IFG should exist for the following groups: (1) immunocompromised patients with intracranial lesions and (2) diabetic patients with intracranial and rhinocerebral mass lesions. Early diagnosis, surgical decompression, and a complete course of promptly initiated antifungal therapy are associated with better prognosis.

The prevalence of intracranial complications in pediatric frontal sinusitis

OBJECTIVE

Intracranial extension of infection represents a serious complication of sinusitis but with no clearly documented prevalence. The frontal sinus with its unique anatomical characteristics, has been singled out as a catalyst for intracranial spread, but without solid evidence. Our objective was to determine the prevalence of intracranial complications in pediatric acute frontal sinusitis and to test the claimed association.

METHODS

A retrospective chart review of all children (</=16 years of age) admitted over an 18 year period with sinusitis was undertaken in a tertiary children's hosiptal. Included were those with acute disease (<3 months duration) that required active medical and/or surgical management. Patients with history of conditions that predispose to rhinosinusitis or intracranial infections were excluded. Data collected included demographics, sinuses involved, intracranial complications and their types, aspects of management, imaging, and mortality.

RESULTS

In our search 466 patients were included. Of these, 386 did not meet the inclusion criteria. Of the 80 remaining patients, 10 had no films or imaging data available for analysis. The 70 included patients ranged in age from 7 months to 15 years (mean 8.8, median 10). Forty-nine (70%) were males. Twenty-six required medical treatment and 44 (62.9%) required surgical therapy in addition. Forty-nine had orbital complications and 8 (11.4%) had intracranial complications. There was no mortality. The eight patients with intracranial complications ranged in age from 3 to 14 years (mean 12). Six were males. Of the 23 patients with frontal sinus involvement, 7 (30.4%) had intracranial complications. The odds ratio for developing intracranial complications if the frontal sinus was involved in the inflammatory process was 20 (95% CI 2.30-176.4).

CONCLUSION

There is a high probability of developing intracranial complications in children who present with acute frontal sinusitis to a tertiary care hospital. This should prompt all involved specialists to insist on detailed radiological evaluation in this group, to halt preventable mortality and morbidity.

Head and Neck Manifestations of Disseminated Coccidioidomycosis

OBJECTIVES/HYPOTHESIS

Coccidioidomycosis is a fungal disease endemic to semiarid regions in the southwestern United States, northern Mexico, and parts of South America. Although this is primarily a pulmonary disease, approximately 0.5% to 1.0% of infected individuals develop disseminated disease affecting skin, subcutaneous tissue, bone, joints, and meninges. The objectives of the study were to present three cases of head and neck manifestations of disseminated coccidioidomycosis and to review the literature of head and neck presentations, diagnosis, and treatment of this potentially life-threatening disease.

STUDY DESIGN

Case reports and literature review.

METHODS

A Medline search was performed with the keyword "coccidioidomycosis." Of 1719 articles in all, 47 were selected for their relevance to otolaryngology, diagnosis, or treatment.

RESULTS

Virtually all head and neck manifestations in patients with disseminated coccidioidomycosis involved the skin, with a predilection for the central face. Systemic symptoms such as fever and cough are often subtle, making the diagnosis difficult. Infections of multiple sites of the head and neck have been reported, including life-threatening airway lesions.

CONCLUSION

The incidence of patients with coccidioidomycosis has been steadily increasing since the late 1980s in endemic areas. Otolaryngologists are increasingly being called on to diagnose and manage the head and neck manifestations of the disease caused by Coccidioides immitis.

The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature

The Pott puffy tumor is a subperiosteal abscess of the frontal bone that appears as a localized swelling of the overlying region of the forehead associated with frontal osteomyelitis. The authors report the case of an 11-year-old boy who presented with a 6-week history of frontal headaches and a recent sudden-onset, progressively enlarging swelling of his midline forehead associated with immediate relief of headaches. A computed tomography (CT) study revealed 1) a subperiosteal abscess with intracranial extension through the perforated posterior table of the frontal sinus and 2) a large epidural abscess overlying a compressed and narrowed superior sagittal sinus. Emergency surgical relief of the epidural abscess, curettage of the osteomyelitic bone, and excision of the periosteal granulomatous puffy lump were performed. A 6-week course of intravenous antibiotic medication was completed, and the patient had an excellent recovery. The Pott puffy tumor remains a serious complication of frontal sinusitis. In the past 5 years, the frequency of published pediatric cases has increased. Undiagnosed or partially treated frontal sinusitis may lead to this serious complication, and the apparent increase in incidence rate may suggest that this complication of frontal sinusitis could be underestimated in clinical practice. The authors conclude that early diagnosis and complete treatment of frontal sinusitis is crucial.

The role of free flaps in the treatment of persistent scalp osteomyelitis

OBJECTIVE

To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis.

METHODS

Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed.

RESULTS

No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants.

CONCLUSION

In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for "chronic" osteomyelitis of the cranium.

Mycobacterium riyadhense infections

Mycobacterium riyadhense is a newly described slowly growing, non-tuberculous mycobacterium species. We describe 2 new cases of Mycobacterium riyadhense infections presenting with extra-pulmonary involvement, and reviewed all previously reported cases in the literature. We also describe the spectrum of the disease and explore treatment options based on the experience with the current and previously reported cases.

Haemophilus influenzae osteomyelitis in adults: a report of 4 frontal bone infections and a review of the literature

Haemophilus influenzae occasionally causes hematogenous long-bone osteomyelitis in children. In adults, however, bone infections caused by this organism are extremely rare. We report four adult cases of H. influenzae frontal bone osteomyelitis and review 12 cases from the literature.

[Osteomyelitis of the frontal bone (Pott's puffy tumor). A report of 5 patients]

BACKGROUND

Frontal bone osteomyelitis is considered to be rare but it may develop intracranial complications such as subperiosteal abscess that appears as a painful fluctuated forehead tumor (Pott's puffy tumor).

METHODS

We reviewed retrospectively the clinical history of those patients showing frontal swelling tumour in our Neurosurgery and Infectious Diseases Departments between July 1994 and December 1997 and whose definitive diagnosis was cranial osteomyelitis.

RESULTS

We reported five cases of patients who had been submitted to a neurosurgical operation between 9 months and 27 years ago. The main clinical features were intermittent painful frontal swelling episodes (with or without fever). These episodes were self-limited or limited after short trend of antibiotics. Imaging techniques were necessary for the diagnosis and especially in order to exclude intracranial complications (such as epidural abscess found in two patients). The ascertain diagnosis is made by debriding, histological studies and cultures from the material. Staphylococcus aureus was isolated in three of the patients, Haemophilus influenzae in one patient and Pseudomonas aeruginosa in the other one. All patients were treated with surgery and specific antibiotic therapy during twelve weeks minimum, being definitively cured.

CONCLUSIONS

It is not well know the etiopathogenic mechanism concerning this rare disease. We remark the importance of a prompt diagnosis because of the high frequency of intracranial complications as well as combined treatment: surgery and long term antibiotic therapy (not less than 8 weeks), is necessary to cure the disease.

[A girl with a swelling on her forehead]

A 9-year-old girl presented with headache and swelling of her forehead caused by a Pott's puffy tumour.

Frontal bone and epidural tuberculosis

Cranial bone and epidural tuberculosis is rare manifestation extrapulmonary tuberculosis. The incidence of tuberculosis of calvaria is on the rise in developing countries because of malnutrition, poor socioeconomic conditions, and immunodeficiency. We present the clinical features, radiology, histopathology, and surgical findings of a case of tuberculosis of the frontal bone with epidural extension. A 46 year-old female had presented with a history of painless right frontal swelling for the previous 4 months. The patient was operated on at a peripheral center for swelling in the right frontal region. In postoperative period, a leak that did not reply to nonspecific antibiotic therapy developed on the lesion. Right frontal epidural effusion was found in the patient who presented our clinic. Histopathological and microbiological examination suggested a diagnosis of tuberculosis.