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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.

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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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