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CASE REPORT
Year : 2007  |  Volume : 10  |  Issue : 4  |  Page : 263-265
 

Why we missed an early diagnosis of cerebral aspergilloma: Lesson from a case


1 Himalayan Institute of Medical Sciences, Swami Ram Nagar, Dehradun, Uttaranchal, India
2 Sanjay Gandhi PGI, Lucknow, India

Correspondence Address:
D Goel
Neurology Department, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Doiwala, Dehradun, Uttaranchal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.37821

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   Abstract 

Intracranial aspergilloma is a dreadful CNS infection with nonspecific clinical manifestation and radiological features. Therefore, delay in the diagnosis is common, resulting in a fatal outcome in almost all the cases. We present how the diagnosis of this condition is overlooked if we do not follow the conventional medical rules of taking history and thorough preoperative evaluation. These clinicoradiological points can be of help in early diagnosis and better outcomes.


Keywords: Aspergillosis, early diagnosis, squash smear


How to cite this article:
Goel D, Bansal K K, Gupta C, Kishor S, Srivastav R K, Raghuvanshi S, Behari S. Why we missed an early diagnosis of cerebral aspergilloma: Lesson from a case. Ann Indian Acad Neurol 2007;10:263-5

How to cite this URL:
Goel D, Bansal K K, Gupta C, Kishor S, Srivastav R K, Raghuvanshi S, Behari S. Why we missed an early diagnosis of cerebral aspergilloma: Lesson from a case. Ann Indian Acad Neurol [serial online] 2007 [cited 2019 Oct 16];10:263-5. Available from: http://www.annalsofian.org/text.asp?2007/10/4/263/37821



   Introduction Top


Aspergilloma is unusually considered as the differential of intracranial mass lesion in the preoperative phase. [1] Their presentation is subtle, often without any diagnostic characteristics and they are frequently mistaken for brain tumors. [2] Therefore, these cases are frequently encountered as a clinical surprise after histological diagnosis.

Many authors had drawn attention about the difficulties in diagnosis of this dreadful condition with nonspecific clinical and radiological findings. [3] The early suspicion of diagnosis is the only method to reduce the high mortality. [3]

We discuss how we failed to initiate a prospective diagnosis in two cases of aspergilloma as an etiology of cerebral mass lesion.


   Case Reports Top


Case 1

A 32-year-old male patient with headache, proptosis, diplopia and progressive Visual loss in left eye for last 3 months was referred to the neurosurgery department. Referral diagnosis was malignant glioma on the basis of brain CT scan finding, showing a lesion in left temporal lobe occupying a large space with contrast enhancement and perifocal edema [Figure - 1]. Preoperative MRI was done by the neurosurgeon for better delineation of the lesion and planning of resection. The surgery was performed with left temporal craniotomy and a bony hard avascular lesion with well-defined margins from the medial to middle temporal gyrus was observed. The tumor was attached to the wall of cavernous sinus. Squash smear per-operatively showed fungal hyphae and histological diagnosis of aspergilloma was finalized [Figure - 2].

Case 2

The second patient was admitted at around 6 months after the first case. This 50-year-old male presented with headache and progressive loss vision for five months. This headache became worse over the time and after the onset of visual symptoms, a CT scan was performed outside that showed large mass in right frontal area. He was referred as malignant glioma. We performed MRI which showed an enhancing right basifrontal lesion with a radiological possibility of anaplastic astrocytoma. Surgery was performed with right frontal craniotomy and excision of tumor. There was solid grayish, firm to hard nonsuckable mass with definite plane of cleavage. Squash smear showed fungal hyphae; later on, it was proved to be aspergillosis.

Two cases of aspergilloma were diagnosed at the interval of 6 months and both were missed preoperatively. The points we missed in favor of diagnosis were very simple related to history taking and clinical examination. Retrospective clinical and radiological analysis was done in both cases after histological diagnosis of aspergilloma. In the detailed histories, first case had measles 6 months back and got some treatment for nasal block and recurrent sinusitis for many time in past, while the second case underwent some nasal surgery for epistaxis 13 years back. Second, the nasopharyngeal examination was not thought to be important. Cerebrospinal fluid (CSF) examination was not done as we were biased for glioma ignored involvement of paranasal air and large venous sinus on MRI [Figure - 3]. Both the patients were nondiabetic and HIV serology was negative. We could not perform other work-up for the assessment of the immune status. Both the patients were administered with amphotericin in postoperative period and both of them died with in 6 months.


   Discussion Top


Aspergillosis is the most common among the fungal infections of CNS; however, on an average, the reporting rates suggest one case per year. [4] The predominant symptoms involve headache, vomiting and cranial-nerve-related symptoms, while the rare symptoms are fever, nasal congestion and seizures. Common signs included papilledema with cranial neuropathy (I, III/IV/VI and V in 4, 7 and 2 patients, respectively), hemiparesis and meningismus. Two-third cases found to have some predisposing immunocompromised state, diabetes being the commonest, while one-third cases have no predisposition. The most common site of involvement is the frontal area followed by the parasalar region. [4]

Our cases are the best examples to reemphasize that taking the clinical history and examination is irreplaceable by technology for reaching a correct diagnosis. Although our patients had a number of clinicoradiological features indicating towards the diagnosis of fungal infection, we could only notice them after histological diagnosis.

Paranasal infections in the past and the topical use of decongestant with steroids might play an important role in predisposing fungal growth. Existing literature have no account for the history of old ENT problems in reported cases; however, radiologically, 40% patients have evidences of paranasal sinus involvement. [4] Fungal infection can directly extend intracranially from the paranasal sinuses. [5],[6],[7] Therefore, at times, intracranial lesions have continuation with paranasal sinuses. The proximity of cranial lesion to the nasal sinus is another point that we had failed to notice in our evaluation. Both the patients had abnormal intensity in the paranasal sinuses and lesions were in close proximity to these sinuses.

The MRI signal characteristics in aspergilloma were compared with the histologic findings. Irregular low-signal zones were demonstrated between the wall of the abscess and the central necrosis on T2-weighted images; the pathology specimen revealed concentrated iron in these transitional zones, but no hemosiderin. Iron is an essential element for the growth of fungal hyphae. The low-signal zones may represent the areas where there was active proliferation of Aspergillus and the unique location of the low signal may be a helpful imaging characteristic for the diagnosis of abscess caused by Aspergillus . [8] This MRI finding was nicely demonstrated in our cases also [Figure - 4].

Large venous sinus thrombosis is the common cause of presentation in fungal infection of CNS. The involvement of superior sagittal and cavernous sinus is common. [9] This point also requires special attention during the MRI evaluation of these patients. All our patients had venous sinus involvement.

We realized from our errors that for the cases with intracranial mass lesions, involving paranasal and venous sinuses and positive nasal problem in past, a detailed nasopharyngeal and paranasal evaluation is more important than rushing for the surgery. This may give the diagnosis in the preoperative stage and the treatment with antifungal drugs can be started early. The opening of vascular channels and the use of corticosteroids in the postoperative period makes the prognosis worst in undiagnosed cases.

The final conclusion is that every patient with intracranial space occupying lesion should be subjected to a systemic approach of clinical history and examination rather than rushing to the operation theater.

 
   References Top

1.Alapatt JP, Kutty RK, Gopi PP, Challissery J. Middle and posterior fossa aspergilloma. Surg Neurol 2006;66:75-9.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Nadkarni T, Goel A. Aspergilloma of the brain: An overview. J Postgrad Med 2005;51:37-41.  Back to cited text no. 2    
3.Fardoun R, Rao NK, Miskeen AK. Cerebral aspergilloma: Review of the literature apropos of a case. Neurochirurgie 1990;36:45-51.  Back to cited text no. 3  [PUBMED]  
4.Dubey A, Patwardhan RV, Sampth S, Santosh V, Kolluri S, Nanda A. Intracranial fungal granuloma: Analysis of 40 patients and review of the literature. Surg Neurol 2005;63:254-60.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Coulthard A, Gholkar A, Sengupta RP. Case report: Frontal aspergilloma: A complication of paranasal aspergillosis. Clin Radiol 1991;44:425-7.  Back to cited text no. 5  [PUBMED]  
6.Wilms G, Lammens M, Dom R, Boogaerts M, Marchal G, Demaerel P, et al. MR imaging of intracranial aspergilloma extending from the sphenoid sinus in an immunocompromised patient with multiple myeloma. J Belge Radiol 1992;75:29-32.  Back to cited text no. 6  [PUBMED]  
7.Swoboda H, Ullrich R. Aspergilloma in the frontal sinus expanding into the orbit. J Clin Pathol 1992;45:629-30.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Yamada K, Zoarski GH, Rothman MI, Zagardo MT, Nishimura T, Sun CC. An intracranial aspergilloma with low signal on T2-weighted images corresponding to iron accumulation. Neuroradiology 2001;43:559-61.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Goel A, Nadkarni T, Desai AP. Aspergilloma in the paracavernous region-two case reports. Neurol Med Chir (Tokyo) 1996;36:733-6.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


This article has been cited by
1 Intracranial Aspergilloma in Immunocompetent Patients Successfully Treated with Radical Surgical Intervention and Antifungal Therapy--Case Series
Srinivasan, U.S.
Ann Acad Med Singapore. 2008; 37(9): 783-787
[Pubmed]



 

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