Surgical Neurology 66 (2006) 75 – 79

www.surgicalneurology-online.com
Infection
Middle and posterior fossa aspergilloma
Jacob P. Alapatt, Mch, FRCS4, Raja K. Kutty, MBBS,
Priya P. Gopi, MBBS, Joseph Challissery, MS
Department of Neurosurgery, Medical College Hospital, Thrissur, Kerala 680001, India
Received 16 July 2005; accepted 29 November 2005

Abstract Background: Aspergilloma of the brain is a rare disease. Among its varied presentations, a solitary
intracranial mass is very uncommon. A preoperative diagnosis of it is very difficult, but a perioperative
squash smear/frozen section can identify the pathology. Because of its rarity in immunocompetent
patients and the difficulty in preoperative diagnosis, we have illustrated this case and its presentation
and management.
Methods: A 27-year-old man presented with an h/o right-sided weakness along with headache and
ear discharge. A computed tomographic (CT) scan showed a large irregular, space-occupying lesion in
the middle and posterior cranial fossa. He had a mastoidectomy done 3 years before for chronic
suppurative otitis media. After a symptom-free interval of 1 year, he was investigated for severe ear-
ache on the same side. A CT scan at that time showed a space occupying mass in the right temporal
bone and right inferior temporal lobe. A biopsy and histopathology of the lesion revealed a chronic
granulomatous mass. He was started on antituberculous drugs and was on it for 7 months at the time
of presentation.
Results: He underwent a suboccipital craniectomy and total excision of the mass. Postoperatively,
his consciousness improved but began to deteriorate on the third postoperative day. A repeat
CT scan showed hydrocephalus and total removal of the mass. An external ventricular drain was
put and he was ventilated, but he died on the fourth postoperative day. Histopathology report came
as aspergilloma.
Conclusion: This report highlights the rare presentation of aspergilloma in an immunocompetent
patient. It emphasizes the importance of suspecting this disease in such patients and the role of
intraoperative squash smear preparations or frozen section in the diagnosis as routine diagnostic
procedures that will help in early pharmacotherapeutic interventions in adjunct to surgery.
D 2006 Elsevier Inc. All rights reserved.
Keywords: Aspergilloma; Middle and posterior fossa

1. Case report copious and present only from the right ear. There was no
history of seizures, visual disturbances, or bowel and bladder
A 27-year-old man was referred to Medical College Hos-
involvement. He was not diabetic and not a known
pital, Thrissur, Kerala, India, with history of headache of
HIV patient.
1 month duration, weakness of right side of the body, and
On examination, he was drowsy but oriented. Ear
right ear discharge for 2 days. Headache was throbbing in
discharge was copious and was yellowish brown, simulating
character not associated with vomiting. Ear discharge was
anchovy sauce. He had right LMN type of facial palsy along
with a grade 3 power in the right upper and lower limbs and
Abbreviations: AIDS, acquired Immuno Deficiency Syndrome; ATT,
grade 5 power on the left side. Deep tendon reflexes were
antituberculous therapy; CNS, central nervous system; CSF, cerebro spinal
fluid; CT, computed tomography; ENT, ear, nose, throat; HIV, human exaggerated over the right side with an extensor plantar
immunodeficiency virus. response. He had cerebellar signs on the right side. There
4 Corresponding author. Tel.: +91 04952354353, +91 9447002931. was no skull or spine deformity.
0090-3019/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.surneu.2005.11.061
76 J.P. Alapatt et al. / Surgical Neurology 66 (2006) 75 – 79
Fig. 1. Computed tomographic scan of the brain showing hyperdense lesion
in the right temporal bone and temporal lobe.
1.1. History
The patient had right ear pain 3 years back. He was
diagnosed as a case of chronic suppurative otitis media and a
mastoidectomy was done by an ENT surgeon. He was
symptom free for 1 year, after which ear pain recurred. A CT
scan showed an osteolytic lesion in the right temporal bone
and right inferior temporal lobe (Figs. 1 and 2). He had a
surgery and biopsy of the lesion by the ENT surgeon and
neurosurgeon in a peripheral hospital. Histopathology came
as a chronic granulomatous disease. After the disease was
presumed to be tuberculosis, he was started on ATT. While
on it for the last 7 months, his clinical status worsened and he
was referred to us for further management.
Routine blood investigations were normal including a
random blood sugar. He was HIV-1 and -2 negative. Chest
x-ray was noncontributory. Computed tomography of the
brain showed a large irregular hyperdense mass lesion in the
right cerebellar hemisphere extending to the right inferior
Fig. 2. Computed tomographic scan showing lesion in the middle fossa,
entering the posterior fossa as well.
Fig. 3. Computed tomographic scan showing larger lesion in the middle and
posterior cranial fossa.
temporal lobe (4.1  5.9  4.0 cm) with destruction of
temporal bone and petrous tympanomastoid (Figs. 3 and 4).
The lesion was totally excised through a right retro-
mastoid suboccipital craniectomy. At surgery, it was grayish,
firm, well encapsulated, and not vascular. It resembled a
tuberculoma but its center was softer than the periphery. The
patient’s consciousness improved after surgery but began to
deteriorate on the third postoperative day. A repeat CT
showed hydrocephalus but no residual lesion (Figs. 5 and 6).
An external ventricular drain was inserted for hydrocephalus
and he was ventilated, but the patient died on the next day.
1.2. Histopathology report
Aspergillosis with significant fibrosis was reported.
Numerous foreign body giant cells were seen containing
septate branching fungal hyphae.
A fungal pathology was not suspected and was not in our
thought spectrum because of the assumption of the granu-
loma to be of tuberculous origin, which is more common in
Fig. 4. Computed tomographic scan showing destruction of the temporal
bone.
 J.P. Alapatt et al. / Surgical Neurology 66 (2006) 75 – 79
Fig. 5. Postoperative CT scan showing complete removal of the lesion
through the posterior fossa craniectomy.
this part of the world. It is also considered as the first and
foremost in the differential diagnosis of a chronic granulo-
matous disease. The immune status of the patient was also in
favor of a tuberculoma rather than a fungal granuloma,
which is more common in an immunocompromised state.
Because there was no routine facility for a squash smear/
frozen section that could have identified the pathology, this
investigation could not be done.
2. Discussion
Aspergillus species are saprophytic moulds found world-
wide. Among about 19 disease-causing species, the most
commonly isolated ones are Aspergillus fumigatus and
Aspergillus flavus. The clinical presentations caused by
these moulds are on a rise worldwide owing to better survival
among immunocompromised hosts [9,16]. The entities
caused by Aspergillus can be grouped into 3 categories:
invasive, allergic bronchopulmonary aspergillosis, and
pulmonary aspergilloma [15].
The invasive disease comprises the infection in various
organs including the CNS. Other sites of infection grouped
into this category are occular infections, aural infections,
sinonasal disease, infection in the lymph nodes, and the like.
The predisposing factors reported so far range from
diabetes, AIDS, malignancy, tuberculosis, renal transplant,
and intranasal steroid use [10] to indiscriminate use of
antitubercular drugs [2]. Our patient was on ATT for
7 months at the time of presentation.
The CNS is the most common secondary site of invasive
aspergillosis after the lung and so is the most dreaded one,
claiming a mortality of more than 90% [15]. The modes
through which this disease spreads to the CNS are
hematogenous, direct, or as a primary intracranial lesion.
Brain abscess, meningitis, epidural abscess [15], vascu-
litis, stroke-like illness [7], and granulomatous mass are the
various types of presentation of CNS aspergillosis. Our
patient presented in the form of a large granuloma involving
77
the middle and posterior fossa, which is rare, as they have a
predilection to the anterior [14] and middle cranial fossa
even in the largest reported series [2]. Brain abscess is the
most common presentation of aspergillosis [10]. Although
granuloma formation is caused by several other species,
Aspergillus is the most commonly isolated fungus [13,15].
The myriad of symptoms by which a patient presents
clinically is mostly due to signs of raised intracranial pres-
sure. Seizures, cranial nerve palsies [11], visual disturbances
[3], subarachnoid hemorrhage, weakness, and ear discharge
are other less common presenting symptoms [2,15]. Our
patient presented with ear discharge, which is relatively rare,
but was a major symptom along with weakness of right
side of the body.
Preoperative diagnosis of an Aspergillus granuloma is a
challenging task. Radiologically, it resembles a meningioma
[3,8], tuberculoma, glioma, or an abscess, all of which have
to be included in the differential diagnosis [2]. However, a
few characteristic appearance of irregular hyperdense lesion
with irregular faint contrast enhancement on CT and inter-
mediate signal intensity on T2-weighted magnetic resonance
imaging scans has been reported in the recent largest series of
intracranial fungal granulomas [2,12]. The presence of such
a finding in a background of immunosuppression should
alert a clinician to the possibility of a fungal etiology. Our
patient tested negative for immunosuppression; hence, such
a thought did not cross our minds.
Laboratory investigations, although less useful owing to
the ubiquitous nature of the moulds, may contribute to the
diagnosis. Newer markers such as Aspergillus galacto-
mannan in urine, cerebrospinal fluid, sera detected by
serially done enzyme-linked immunosorbent assay, enzyme
immunoassay, or immunoblot have given encouraging
results with a positive predictive value of 54% and a
negative predictability of 95% [15].
The treatment options for CNS aspergillosis can be
medical or surgical depending on the clinical graveness of
the disease. Medical treatments comprise intravenous
Fig. 6. Postoperative CT scan showing dilated temporal horns—hydro-
cephalus.
78 J.P. Alapatt et al. / Surgical Neurology 66 (2006) 75 – 79
amphotericin B in a maximum tolerable dose of 1 to
1.5 mg/kg per day. Its systemic toxicity and poor CNS
penetration are usually balanced by addition of synergists
such as flucytosine. Some authors recommend a direct
intracavitary administration of amphotericin B via an
indwelling catheter to counteract this problem [1]. Itraco-
nazole, a triazole derivative, which is a fungistat, is found to
be effective against Aspergillus. Other triazoles found to
have activity against Aspergillus include variconazole,
posaconazole, and ravuconazole [15]. Caspofungin is
another drug found to be effective in resistant cases.
Surgical treatment options considered so far are stereo-
taxy and biopsy to establish a diagnosis and sterotactic drain-
age of abscess [6] and craniotomy and excision to reduce the
mass effect. Our patient presented with features of raised
intracranial pressure with mass effect; hence, its excision was
inevitable. At surgery, this lesion closely resembled a
tuberculoma. A squash smear or a frozen section could
easily identify the fungal etiology, if it was sent for as a
routine practice. As it was not, the diagnosis was made late
and only after a histopathology report was available.
Hydrocephalus, a less common sequelae, usually neces-
sitates a temporary ventricular drainage or a permanent
ventricular shunt placement if it has become chronic [2]. This
happened in our case too, and we resorted to a temporary
ventricular drainage along with hyperventilation. Other less
common complications such as death due to massive
anaphylaxis [7] and vascular infarcts remote from the site
of surgery [4] are also reported.
The prognosis of CNS aspergillosis is unpredictable. The
mortality range differs in different published series until
now. However, the latest series on intracranial fungal granu-
lomas concluded with a mortality of 63%. Some authors
suggest early diagnosis and preoperative medical manage-
ment with amphotericin B followed by surgery improve the
prognosis [5,14].
3. Conclusion
A possibility of a fungal granuloma should be thought of
in the differential diagnosis of an intracranial solitary mass,
even in an immunocompetent host. A perioperative squash
smear or a frozen section should be sought after in the
evaluation of this disease. If done so and a fungal etiology is
identified, then only a part of the specimen should be put in
formalin and the rest should be sent in normal saline to do a
fungal culture.
References
[1] Camarata PJ, Dunn DL, Farney AC, Parker RG, Seljeskog EL.
Continual intracavitary administration of amphotericin B as an adjunct
in the treatment of Aspergillus brain abscess: case report and review of
the literature. Neurosurgery 1992;31(3):575 - 9.
[2] Dubey A, Patwardhan RV, Sampth S, Santosh V, Kolluri S, Nanda A.
Intracranial fungal granuloma: analysis of 40 patients and review of
the literature. Surg Neurol 2005;63:254 - 60.
[3] Fardoun R, Rao NK, Miskeen AK. Cerebral aspergilloma. Review of
the literature apropos of a case. Neurochirurgie 1990;36(1):45 - 51.
[4] Goel A, Nadkarni T, Desai AP. Aspergilloma in the paracavernous
region — two case reports – India. Neurol Med Chir (Tokyo) 1996;
36(10):733 - 6.
[5] Golin V, Sprovieri SR, Cancado JE, Daniel JW, Mimica LM.
Aspergillosis of the central nervous system. Sao Paulo J Med 1996;
114(5):1274 - 7.
[6] Goodman ML, Coffey RJ. Stereotactic drainage of Aspergillus brain
abscess with long term survival case report and review. Neurosurgery
1989;24(1):96 - 9.
[7] Haran RP, Chandy J. Intracranial Aspergillus granuloma. Br J Neurol
1993;7(4):383 - 8.
[8] Kchir N, Bouratbine A, Boubaker S, Jemel H, Haouet S, Chatti S,
Khaldi M, Zitouna MM. Cerebral aspergillotic granuloma. Apropos of
a case and a review of the literature. Neuro-Chirurgie 1990;
36(2):132 - 6.
[9] Levy RM, Bredsen DE, Rosenblum ML. Neurological manifestations
of the acquired immuno deficiency syndrome (AIDS) experience at
UCSF and review of literature. J Neurosurg 1985;62(4):475 - 95.
[10] Lewis MB, Henderson B. Invasive intracranial aspergillosis secondary
to intranasal corticosteroids. J Neurol Neurosurg Psychiatry 1999;
67:416.
[11] Manfred P, Jurgen H, Franz D, Friedrich F, Zentner J. Fungal
granuloma of the sphenoid sinus and clivus in a patient presenting
with cranial nerve III paresis: case report and review of the literature.
Neurosurgery 2003;52(4):955 - 9.
[12] Mikhael MA, Rushovich AM, Ciric I. Magnetic resonance imaging
of cerebral aspergillosis. Comput Radiol 1985;24(1):96 - 9.
[13] Murthy JM, Sundaram C, Prasad VS, Purohit AK, Rammurti S, Laxmi
V. Aspergillosis of central nervous system: a study of 21 patients seen
in a university hospital in South India. J Assoc Physicians India
2000;48(7):677 - 81.
[14] Satoh H, Uozumi T, Kiya K, Ikawa F, Kurisu K, Sumida M, Nakahara
A. Invasive aspergilloma of the frontal base causing internal carotid
artery occlusion. Surg Neurol 1995;44(5):483 - 8.
[15] Stevens DA, Kan VL, Judson MA, Morrison VA, Dummer S,
Denning DW, Bennett JE, Walsh TJ, Patterson TF, Pankey GA.
Practice guidelines for diseases caused by Aspergillus. Clin Infect Dis
2000;30:696 - 7.
[16] Walsh TJ, Hier DB, Caplan LR. Fungal infections of the CNS.
Comparative analysis of risk factors and clinical signs in 57 patients.
Neurology 1985;35(11):1654 - 7.
Commentary
Aspergillosis is a term used to describe an illness caused
by one of at least 16 species of Aspergillus, an ubiquitous
mold that may cause colonization, allergy, or tissue invasion.
The fungus grows well on stored hay, decaying vegetation,
soil, and compost piles. Little wonder that this ubiquity in the
environment exposes patients to infection in the lung,
paranasal sinuses, external ear, and traumatized skin that
can serve as a nidus for central nervous system infection.
Aspergillus infections have recently been diagnosed more
often in neurosurgical patients, in part due to an increased
number of immunosuppressed individuals due to such
diseases as a variety of neoplasms, AIDS, chronic granulo-
matous disease, aging, and immunosuppression with drugs
and in part due to better imaging techniques including
computerized tomography and magnetic resonance imaging.