Intracranial fungal granuloma: analysis of 40 patients and review of the literature.
OBJECTIVE
To describe the characteristics of patients diagnosed with intracranial fungal granuloma (IFG) in the largest reported series to date (to our knowledge).


METHODS
A 22-year retrospective, multi-institutional review of 40 patients, aged 16 to 62 years (mean, 40.2 years), was performed in patients with histopathologically confirmed IFG. The variables were symptoms/signs at presentation, predisposing factors, location of granuloma, involvement of paranasal sinuses, diagnostic studies including blood and urine cultures, surgical procedures performed, specific organism identified, treatment, and prognosis. Plain x-rays, computed tomography, and/or magnetic resonance imaging scans were performed.


RESULTS
Predominant symptoms included headache (83%), vomiting (65%), proptosis (48%), and visual disturbances (48%). Other symptoms were fever, nasal congestion, and seizures (7 [18%]). Common signs included papilledema (12 [30%]), with cranial neuropathy (I, III/IV/VI, and V in 4, 7, and 2 patients, respectively), hemiparesis (3), and meningismus (3). Predisposing factors were diabetes (16 [40%]), tuberculosis (7 [18%]), and immunocompromise related to renal transplant (2), non-Hodgkin's lymphoma (1), and human immunodeficiency virus (1). Location was primarily frontal (10 [25%]), with anterior cranial fossa involved in 8 (20%) patients; 6 (15%) patients had sellar/parasellar involvement. Eighteen (40%) had paranasal sinus involvement. Twenty-nine patients underwent craniotomy for resection, with 11 undergoing biopsy (of which 3 were transsphenoidally approached). Histopathology revealed aspergilloma (25 [63%]), mucormycosis (7 [18%]), cryptococcoma (3), cladosporidium (3), Bipolaris hawaiiensis (1), and Candida species(1). Microbiological analysis of the specimen was positive in 28 (60%) patients. All patients were treated with amphotericin B, fluconazole, and/or flucytosine. Only 26 patients completed amphotericin B therapy (due to nephrotoxicity). Mortality was 63%, most commonly due to meningoencephalitis (16 [36%]).


CONCLUSIONS
High index of suspicion of IFG should exist for the following groups: (1) immunocompromised patients with intracranial lesions and (2) diabetic patients with intracranial and rhinocerebral mass lesions. Early diagnosis, surgical decompression, and a complete course of promptly initiated antifungal therapy are associated with better prognosis.
Dubey
Arvind
A
Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71130-3932, USA.
Patwardhan
Ravish V
RV
Sampth
Sammana
S
Santosh
Vani
V
Kolluri
Sastry
S
Nanda
Anil
A
D000293:Adolescent; D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use; D001927:Brain Diseases / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D020314:Central Nervous System Fungal Infections / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D002648:Child; D035262:Cranial Fossa, Anterior / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D003389:Cranial Nerve Diseases / Q000382:microbiology / Q000473:pathology / Q000503:physiopathology; D048909:Diabetes Complications / Q000382:microbiology / Q000473:pathology / Q000503:physiopathology; D005260:Female; D005624:Frontal Bone / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D005658:Fungi / Q000166:cytology / Q000502:physiology; D006099:Granuloma / Q000175:diagnosis* / Q000382:microbiology* / Q000628:therapy; D006801:Humans; D016867:Immunocompromised Host / Q000276:immunology; D007165:Immunosuppression Therapy / Q000009:adverse effects; D008297:Male; D008578:Meninges / Q000382:microbiology / Q000473:pathology; D008875:Middle Aged; D010254:Paranasal Sinus Diseases / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D012189:Retrospective Studies; D012658:Sella Turcica / Q000382:microbiology / Q000473:pathology; D012886:Skull / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D019291:Skull Base / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D014057:Tomography, X-Ray Computed
D000935:Antifungal Agents