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True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery.

Radotra BD, Salunke P, Parthan G, Dutta P, Vyas S, Mukherjee KK - Surg Neurol Int (2015)

Bottom Line: Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus.The possibility of intracranial fungal infection should be strongly considered in any patient receiving intrathecal antibiotics who fails to improve in 1-2 weeks, and frequent CSF culture for fungi should be performed to confirm the diagnosis.Since CSF culture has poor sensitivity in the diagnosis of fungal infections of CNS; empirical institution of antifungal therapy may be considered in this scenario.

View Article: PubMed Central - PubMed

Affiliation: Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

ABSTRACT

Background: Immunosuppressive therapy, prolonged antibiotic use, and intrathecal injections are known risk factors for the development of invasive aspergillosis. Central nervous system (CNS) aspergillosis can manifest in many forms, including mycotic aneurysm formation. The majority of the mycotic aneurysms presents with subarachnoid hemorrhage after rupture and are associated with high mortality. Only 3 cases of true mycotic aneurysms have been reported following trans-sphenoidal surgery.

Case description: A 38-year-old man was admitted with nonfunctioning pituitary adenoma for which he underwent trans-sphenoidal surgery. Three weeks later, he presented with cerebrospinal fluid (CSF) rhinorrhea and meningitis. He was treated with intrathecal and intravenous antibiotics, stress dose of glucocorticoids, and lumbar drain. The defect in the sphenoid bone was closed endoscopically. After 3 weeks of therapy, he suddenly became unresponsive, and computed tomography of the head showed subarachnoid hemorrhage. He succumbed to illness on the next day, and a limited autopsy of the brain was performed. The autopsy revealed extensive subarachnoid hemorrhage and aneurysmal dilatation, thrombosis of the basilar artery (BA), multiple hemorrhagic infarcts in the midbrain, and pons. Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus.

Conclusion: The possibility of intracranial fungal infection should be strongly considered in any patient receiving intrathecal antibiotics who fails to improve in 1-2 weeks, and frequent CSF culture for fungi should be performed to confirm the diagnosis. Since CSF culture has poor sensitivity in the diagnosis of fungal infections of CNS; empirical institution of antifungal therapy may be considered in this scenario.

No MeSH data available.


Related in: MedlinePlus

Cut section of brain showing extensive subarachnoid hemorrhage and ruptured basilar artery aneurysm
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Figure 3: Cut section of brain showing extensive subarachnoid hemorrhage and ruptured basilar artery aneurysm

Mentions: The cause of death was speculated to be due to rupture of an intracranial aneurysm. This may have been an association with pituitary macroadenoma (although it is seen often with functioning pituitary macroadenoma), or due to the weakening of vessel wall due to inflammatory exudates. The third possibility could be an inadvertent intraoperative injury such as snapping of a perforator from a distal vessel, resulting in pseudoaneurysm formation. To confirm the cause of death, a limited brain autopsy was performed, which revealed extensive subarachnoid hemorrhage and aneurysmal dilatation and thrombosis of the basilar artery (BA) [Figure 3]. There were multiple hemorrhagic infarcts in the midbrain and pons. Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus [Figure 4a–d].


True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery.

Radotra BD, Salunke P, Parthan G, Dutta P, Vyas S, Mukherjee KK - Surg Neurol Int (2015)

Cut section of brain showing extensive subarachnoid hemorrhage and ruptured basilar artery aneurysm
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4697199&req=5

Figure 3: Cut section of brain showing extensive subarachnoid hemorrhage and ruptured basilar artery aneurysm
Mentions: The cause of death was speculated to be due to rupture of an intracranial aneurysm. This may have been an association with pituitary macroadenoma (although it is seen often with functioning pituitary macroadenoma), or due to the weakening of vessel wall due to inflammatory exudates. The third possibility could be an inadvertent intraoperative injury such as snapping of a perforator from a distal vessel, resulting in pseudoaneurysm formation. To confirm the cause of death, a limited brain autopsy was performed, which revealed extensive subarachnoid hemorrhage and aneurysmal dilatation and thrombosis of the basilar artery (BA) [Figure 3]. There were multiple hemorrhagic infarcts in the midbrain and pons. Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus [Figure 4a–d].

Bottom Line: Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus.The possibility of intracranial fungal infection should be strongly considered in any patient receiving intrathecal antibiotics who fails to improve in 1-2 weeks, and frequent CSF culture for fungi should be performed to confirm the diagnosis.Since CSF culture has poor sensitivity in the diagnosis of fungal infections of CNS; empirical institution of antifungal therapy may be considered in this scenario.

View Article: PubMed Central - PubMed

Affiliation: Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

ABSTRACT

Background: Immunosuppressive therapy, prolonged antibiotic use, and intrathecal injections are known risk factors for the development of invasive aspergillosis. Central nervous system (CNS) aspergillosis can manifest in many forms, including mycotic aneurysm formation. The majority of the mycotic aneurysms presents with subarachnoid hemorrhage after rupture and are associated with high mortality. Only 3 cases of true mycotic aneurysms have been reported following trans-sphenoidal surgery.

Case description: A 38-year-old man was admitted with nonfunctioning pituitary adenoma for which he underwent trans-sphenoidal surgery. Three weeks later, he presented with cerebrospinal fluid (CSF) rhinorrhea and meningitis. He was treated with intrathecal and intravenous antibiotics, stress dose of glucocorticoids, and lumbar drain. The defect in the sphenoid bone was closed endoscopically. After 3 weeks of therapy, he suddenly became unresponsive, and computed tomography of the head showed subarachnoid hemorrhage. He succumbed to illness on the next day, and a limited autopsy of the brain was performed. The autopsy revealed extensive subarachnoid hemorrhage and aneurysmal dilatation, thrombosis of the basilar artery (BA), multiple hemorrhagic infarcts in the midbrain, and pons. Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus.

Conclusion: The possibility of intracranial fungal infection should be strongly considered in any patient receiving intrathecal antibiotics who fails to improve in 1-2 weeks, and frequent CSF culture for fungi should be performed to confirm the diagnosis. Since CSF culture has poor sensitivity in the diagnosis of fungal infections of CNS; empirical institution of antifungal therapy may be considered in this scenario.

No MeSH data available.


Related in: MedlinePlus