M.S.

Gopalakrishnan
Asst Professor, Neurosurgery
JIPMER
23 year old manual laborer
Increasing headache with vomiting for 1
month
On examination, he was distressed due to
headache, but was well oriented.

He had bilateral papilledema and anosmia.

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Routine hematological and biochemical
parameters were normal
Chest X-ray was normal
HIV serology was negative
He was initially investigated in hospital
elsewhere and had undergone a transnasal
biopsy

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He was treated with antibiotics for 14 days in
2004 in Jipmer when he lapsed into altered
sensorium following fever and headache of a
single day’s duration.

Although meningitis or subarachnoid

hemorrhage were suspected, CSF study was
documented as normal.

Currently he was not on any medicines

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The extension into the ethmoids were excised and the
anterior cranial fossa base was repaired with
vascularised pericranial graft

Procedure was done under the cover of maintenance

dose of amphotericin B
[1.5 mg/kg/day]
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Raised ICP features resolved
Patient is on amphotericin B 60 mg /day
Renal parameters are within normal limits.

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Plain ct scan Contrast 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 and
large vessels and cause thrombosis and
infarcts

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Cause of death

Mass effect and herniation due to abscesses

and edema
Massive hemorrhagic infarcts
Rupture of mycotic aeurysms

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What was the cause of altered sensorium four
years back?

Does extensive tinea versicolor and invasive

aspergillosis indicate a as yet undiagnosed
immunocompromised condition in this patient,
especially to fungal pathogens?

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Suspect invasive aspergillosis if there is
involvement of paranasal sinuses
Can occur in immunocompetent
Aggressive surgical excision, including
multiple surgeries at multiple sites may be
required.
Start amphotericin B straightaway at high
maintainance doses of 1.5 mg/kg/day…
cumulative doses up to 10 grams followed by
high dose oral itraconazole.
Voriconazole is a better option if patient can
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afford.
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