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M.S. Gopalakrishnan
Asst Professor, Neurosurgery
JIPMER
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23 year old manual laborer
Increasing headache with vomiting for 1month
On examination, he was distressed due toheadache, but was well oriented.
He had bilateral papilledema and anosmia.
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Routine hematological and biochemicalparameters were normal
Chest X-ray was normal
HIV serology was negative
He was initially investigated in hospitalelsewhere and had undergone a transnasalbiopsy
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He was treated with antibiotics for 14 days in2004 in Jipmer when he lapsed into alteredsensorium following fever and headache of asingle day’s duration.
Although meningitis or subarachnoidhemorrhage were suspected, CSF study was
documented as normal.
Currently he was not on any medicines4gk160509
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The extension into the ethmoids were excised and theanterior cranial fossa base was repaired with
vascularised pericranial graft
Procedure was done under the cover of maintenancedose of amphotericin B
[1.5 mg/kg/day]
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Raised ICP features resolved
Patient is on amphotericin B 60 mg /dayRenal parameters are within normal limits.
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Plain ct scanContrast scan
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Very lethal condtion!95% mortality even with all treatment
Usually affect the immunosuppressed.Fungus is angioinvasive.
Destroys internal elastic layer of medium andlarge vessels and cause thrombosis and
infarcts
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Cause of death
Mass effect and herniation due to abscessesand edema
Massive hemorrhagic infarcts
Rupture of mycotic aeurysms
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What was the cause of altered sensorium fouryears back?
Does extensive tinea versicolor and invasiveaspergillosis indicate a as yet undiagnosedimmunocompromised condition in this patient,especially to fungal pathogens?
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Suspect invasive aspergillosis if there isinvolvement of paranasal sinuses
Can occur in immunocompetent
Aggressive surgical excision, includingmultiple surgeries at multiple sites may berequired.
Start amphotericin B straightaway at high
maintainance doses of 1.5 mg/kg/day…cumulative doses up to 10 grams followed byhigh dose oral itraconazole.
Voriconazole is a better option if patient can
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