title: Intracranial fungal granuloma: analysis of 40 patients and review of the literature.
abstract: 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.
authors.affiliation: Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71130-3932, USA.
authors.forename: Arvind
authors.initials: A
authors.lastname: Dubey
authors.forename: Ravish V
authors.initials: RV
authors.lastname: Patwardhan
authors.forename: Sammana
authors.initials: S
authors.lastname: Sampth
authors.forename: Vani
authors.initials: V
authors.lastname: Santosh
authors.forename: Sastry
authors.initials: S
authors.lastname: Kolluri
authors.forename: Anil
authors.initials: A
authors.lastname: Nanda
mesh_terms: 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
chemical_list: D000935:Antifungal Agents