Surgical treatment for fungal infections in the central nervous system

Abstract

The hospital records of 78 patients who underwent surgical therapy for fungal infections of the central nervous system (CNS) between 1964 and 1984 are summarized. Nine different fungal types were identified, but Coccidioides immitis and Cryptococcus neoformans accounted for most (67.1%) of the infections. A variety of clinical syndromes were seen, including chronic basal meningitis (45 patients), intracranial mass lesions (12 patients), and communicating hydrocephalus (six patients). Thirteen patients had rhinocerebral forms of fungal infection, and two presented with spinal involvement. Delays in diagnosis were frequent and ranged from 2 months to 11 years. In 31 patients the CNS lesion was the first indication of a fungal infection, and lesion biopsy or cerebrospinal fluid (CSF) examination confirmed the diagnosis. A total of 144 surgical procedures were carried out, including lesion biopsy or excision in 13 patients, primary CSF shunting in 22, and placement of an Ommaya reservoir for administration of intraventricular or intracisternal antifungal agents in 48. All patients received parenteral and, in some cases, intrathecal or oral antifungal chemotherapy in addition to surgical therapy. Overall mortality was 43.6% (34 deaths). With prompt diagnosis and treatment, the mortality rate was 39% whereas, when appropriate treatment was delayed, the mortality rate was 64%. An additional 14 surviving patients (17.9%) exhibited permanent morbidity due to neurological deficits, seizure disorders, or renal toxicity following treatment with amphotericin B. The combined mortality and morbidity rate was 62.8%. Clinical symptoms were resolved completely in 29 patients, although in 10 evidence of disease persisted and chemotherapy was continued. Fungal infections of the CNS are being recognized with increased frequency. It is suggested that a high index of suspicion, aggressive attempts to obtain a diagnosis, and early and vigorous therapy may reduce the unfortunate outcome seen in a relatively high proportion of patients with CNS fungal infections.

Tissue Penetration of Antifungal Agents

“…In contrast to the case with posaconazole, inflammation does not seem to increase the concentration of any amphotericin formulation in the brain, at least in animals (40,92). To overcome these potential limitations, intraventricular instillation of AmBd via an Ommya reservoir has been used for severe cerebral infections (93,94,95).…”

Candida Albicans Dural Granuloma: Case Report

“…2,4,5) Even larger case series include a limited number of patients recruited in a long time interval. 5,11) Diabetes is one of the most frequent predisposing causes for disseminated fungal infections, which are also frequently associated with immunocompromised status. 8,9) The rising incidence of diabetes, especially in underdeveloped countries, has led to an increase of intracranial fungal masses, intracerebral abscesses, and granulomas due to Candida species.…”

“…The spreading of mycotic infections to the intracranial compartment is relatively a rare event and rarer is the need of neurosurgical procedures for the removal of fungal masses, either developing inside the brain as abscesses or in the epidural space as granulomas. 1,[9][10][11] The more frequently involved species affecting human brain include Cryptococcus neoformans, Aspergillus flavus, Aspergillus fumigatus, Actinomyces israeli, Nocardia asteroides, and Candida albicans. 1,6) Clinical syndromes with which fungal infections may affect the CNS are protean, occurring alone or in combination, sometimes being specific for peculiar organisms (as for the rhinocerebral form of zygomycosis) and typically present as meningitis, intracranial mass lesions, and anterior skull base granulomas.…”

“…Surgical treatment aimed at mass removal is usually considered only for well circumscribed and superficial lesions and must always be associated with prolonged antimycotic therapy. [9][10][11] We report an unusual case of intracranial granuloma from Candida albicans, developing exclusively within the dural envelope and causing severe neurological symptoms leading to emergency neurosurgical treatment.…”

Forma granulomatosa da criptococose cerebral: relato de caso

“…A criptococose é infecção fúngica que tem por agente etiológico o Cryptococcus neoformans, sendo freqüentemente contraída pela inalação do fungo de solos ricos em excretos de pombos, evoluindo inicialmente com sintomas pulmonares que no princípio podem cursar desapercebidos ao paciente 7,15,17 . Quando do diagnóstico inicial de criptococose, 70% dos pacientes apresentam sintomas neurológicos 3,11 .…”