title: True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery.
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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Bishan Das
authors.initials: BD
authors.lastname: Radotra
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Praveen
authors.initials: P
authors.lastname: Salunke
authors.affiliation: Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Girish
authors.initials: G
authors.lastname: Parthan
authors.affiliation: Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Pinaki
authors.initials: P
authors.lastname: Dutta
authors.affiliation: Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Sameer
authors.initials: S
authors.lastname: Vyas
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Kanchan K
authors.initials: KK
authors.lastname: Mukherjee
keywords: Aspergillosis; basilar artery; mycotic aneurysm; pituitary adenoma; subarachnoid hemorrhage; trans-sphenoidal surgery