Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient

Abstract

Pterygopalatine fossa Magnetic resonance imaging A B S T R A C T Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly found inimmunocompromised patients but rarely seen among immunocompetent patients. Herein we describe a 57 year-old immunocompetent man who suffered intracranial aspergillosis spread by the pterygopalatine fossa (PPF) following a tooth extraction. Based on magnetic resonance imaging (MRI) characteristics, in this report we focus on the spreading routes of CNS aspergillosis via communicative structures of the PPF, the relationship between clinical manifestations and the locations of the lesion, and propose a therapeutic strategy to improve the prognosis.© 2012 Elsevier Editora Ltda. All rights reserved. Case presentationA 57-year-old male had suffered from persistent headache for 20 months on the left occipitotemporal side after a tooth extraction, followed by a decrease of his left visual acuity and disordered speech. On neurological examinations, his left eye fixed with light reflex disappeared, the ipsilateral palpebral fissure became narrow in response to his eyelid weakness, and the temporalis and masseter muscles were weak with apparent atrophy. Moreover, his left side hearing declined, his left face felt numb, and his memory deteriorated. On magnetic resonance imaging (MRI) of the head, an enlarged mass with hypo-intense signal on T2WI and T1WI in the left pterygopalatine fossa (PPF) was shown, involving the ipsilateral sphenoid sinus, cavernous sinus, inferior orbital fissure, and temporal and frontal lobes. The left pterygopalatine canal was obviously enlarged with abnormal signal intensity. The contrast enhanced T1WI showed strong enhancement at the aforementioned regions (Fig. 1). In order to confirm the nature of the mass, a transnasal biopsy of the PPF was carried out. The histological result revealed the rare finding of Aspergillus. Antifungal therapy was immediately started with vorionazole and amphotericin B. However, his condition was not satisfactorily under control after a long period of antibiotic therapy. A surgical operation was then arranged, and preoperation examinations were completed. The patient underwent a left pterion craniotomy with resection of skull base occupying lesions. The multiple intradural lesions were excised, and Aspergillus was proved again by intraoperative biopsy. The lesion had a light yellowish color and a hard consistency that was tightly adhered to the nearby tissue, especially to the left middle cerebral artery. After incision, the

A Rare Case of Invasive Central Nervous System Aspergillus niger in a Previously Immunocompetent Patient After Corticosteroid Treatment for COVID-19

“…CNS-invasive disease is associated with the highest mortality rate of all invasive aspergillosis syndromes, with up to 90% in most series [ 13 ]. The overall prognosis of intracranial Aspergillus is poor in both immunocompromised and immunocompetent patients [ 9 ].…”

“…Imaging in CNS aspergillosis can demonstrate sinonasal disease with intracranial extension (rhinocerebral disease), multiple or solitary mass-like parenchymal lesions, and/or meningeal involvement, with possible granuloma formation. Imaging appearances vary according to the site of involvement, but isolated mass-like parenchymal lesions are typically hypo- to iso-intense signals on T1-weighted and T2-weighted imaging, with heterogeneous peripheral enhancement on post-gadolinium imaging [ 1 , 9 ]. Aspergillus abscesses may also demonstrate peripheral low-signal intensity on T2-weighted images due to perilesional hemorrhage.…”

Transorbital Endoscopic Approach to the Pterygopalatine Fossa: A Less Invasive Alternative to Traditional Access

“…In bacterial and fungal infections, the PPF can act as a conduit for spread, given its numerous communications to surrounding anatomic regions. 1,13,14 Inflammatory lesions can also involve the PPF. Transorbital endoscopic access can be considered in cases with pathology involving the superior portion of the PPF and requiring only an incisional biopsy.…”

Intracranial aspergilloma mimicking metachronous meningioma following transsphenoidal removal of a tuberculum sellae meningioma: illustrative case

“…The mortality of CNS aspergillosis is estimated to be as high as 40%–80%. 19 , 22 This high mortality rate may be due to the potential vascular complications of aspergillosis infection and the often impaired immunity of the affected patients; thus, these factors should be thoroughly investigated. 23 In contrast, aspergillosis infection forming a solid mass has a relatively good prognosis.…”