Blastomycosis of the Skull Base

Abstract

Blastomycosis is a nonopportunistic fungal infection caused by Blastomyces dermatitides. Originally described by Gilchristl as a cutaneous infection, it is now accepted as a systemic disease with many classic and unusual presentations. Although pulmonary and cutaneous involvement is frequently seen, head and neck blastomycoses is less common. Middle ear, paranasal sinus, and temporal bone involvement are exceedingly rare. We present a case of a patient with blastomycosis of the middle ear, temporal bone, and paranasal sinuses, with massive base of skull destruction, in the absence of primary pulmonary involvement. CASE REPORTA 57-year-old black woman was transferred from an outside hospital where she had been treated for intractable otorrhea and lateral head pain. Eighteen months earlier, she had undergone a left Caldwell-Luc procedure, along with placement of a ventilation tube for a left middle ear effusion. She underwent a left radical mastoidectomy for persistent drainage 6 months later. The previous otologic surgeon described removal of a cholesteatoma. Since that time, the patient had persistent drainage from the left ear, progressive left-sided hearing loss, and temporal headaches. At the outside hospital, the patient was receiving parenteral ceftazadime, ampicillin, vancomycin, and metronidazole without resolution of drainage or pain. The remainder of the patient's past medical history was unremarkable. No significant systemic diseases were present. Human immunodeficiency virus serology was negative.The head and neck examination, including neurologic evaluation, was normal with the exception of purulent drainage from the left ear. An audiogram demonstrated a profound left hearing loss. The patient was afebrile on admission, and laboratory values were within normal limits. The white blood cell count was normal. Cultures of the left ear drainage from the previous hospital grew Staphylococcus aureus and stains for acid-fast bacilli were negative. An admission chest radiograph revealed "diffuse interstitial changes likely representative of chronic fibrotic changes." No evidence of granulomatous disease was seen.Magnetic resonance imaging with gadolinium demonstrated an extensive process involving the infratemporal fossa, middle ear, and mastoid air cells (Fig. 1). Extension into the epidural space was evident. Left temporal lobe edema was present. The sphenoid sinus was filled with soft tissue and mucosal thickening of the left maxillary sinus was demonstrated (Fig. 2).Computed tomography revealed multiple destructive lesions involving the base of the skull, sphenoid sinus, right maxillary sinus, with involvement of the hard palate, nasal cavity, and ethmoid sinus. A destructive lesion was also noted to involve the petrous portion of the left temporal bone with obliteration of the foramina contiguous to the sphenoid sinus (Fig. 3). The computed tomography (CT) scan was interpreted by the neuroradiologist as multiple metastatic lesions.Our preoperative differential diagnoses included metastatic carcinoma and ...

Cerebral Blastomycosis in a Tunisian Woman

“…There are no well-documented cases of manto-man, man-to-animal, or animal-to-animal transmissions [7].…”

“…The 2-hydroxystilbamidine had an acceptable cure rates in patients in whom the blastomycosis has been slowly progressive and of limited extent, confined to the lung and the skin. Ketoconazole was also recently used in few selected patients with some cures [1,[5][6][7].…”

“…This is possibly due to hematogenous spread of the infection to the brain. Chronic meningitis is the more frequent form of presentation, but cerebral and extra dural abscesses, intraparenchymal granulomas, and cerebritis have also been reported [5][6][7].…”