Intracranial Aspergilloma in Immunocompetent Patients Successfully Treated with Radical Surgical Intervention and Antifungal Therapy – Case Series

Abstract

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. Key words: Central nervous system aspergillosis, Aspergilloma, Itraconazole, Voriconazole

Sphenoid Sinus Aspergilloma in an Immunocompetent and an Immunocompromised Patient: A Case Report

“…Voriconazole and other azole drugs are often preferred over amphotericin-B because of their better safety profile, as they carry a decreased risk of nephrotoxicity as well as infusion-related reaction. Liposomal formulations of amphotericin-B tend to be better tolerated, however, are very expensive compared to azole drugs [ 10 ]. Additionally, voriconazole can be used as an oral drug for long-term treatment, as the oral formulation carries a >90% bioavailability, the same as the intravenous formulation [ 11 ].…”

“…Additionally, surgical debridement decreases the mass effect and relieves the pressure on the optic apparatus and other cranial nerves, thus providing more immediate symptomatic relief to patients. The angioinvasive nature of CNS aspergilloma also puts patients at risk for thrombosis or infarction; this ultimate progression to vessel invasion or intracerebral hemorrhage may be prevented by adequate surgical resection [ 6 , 10 ]. The different approaches of neurosurgical intervention include craniotomy with abscess resection, transnasal transsphenoidal approach, abscess drainage, or shunt placement.…”

“…However, due to the limited differentiation of solid tumors based on imaging alone, an accurate diagnosis of cerebral aspergilloma is made with a combination of imaging, surgical histopathology, and clinical features. On MR imaging aspergilloma is hypointense on both T1WI and T2WI, whereas CT imaging tends to show a hyperdense lesion [ 10 ]. Additionally, MR imaging may show the presence of hypointense zones within areas of T2 hyperintense mass, which is specific to aspergillus infection.…”