Scandinavian Journal of Infectious Diseases

ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19

Invasive intracranial aspergillosis in an

immunocompetent patient after dental extraction

Bo Yan, Xingtong Wu & Dong Zhou

To cite this article: Bo Yan, Xingtong Wu & Dong Zhou (2011) Invasive intracranial aspergillosis
in an immunocompetent patient after dental extraction, Scandinavian Journal of Infectious
Diseases, 43:2, 156-158

To link to this article: http://dx.doi.org/10.3109/00365548.2010.527858

Published online: 03 Nov 2010.

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 Scandinavian Journal of Infectious Diseases, 2011; 43: 156–158

CASE REPORT

Invasive intracranial aspergillosis in an immunocompetent patient

after dental extraction

BO YAN, XINGTONG WU & DONG ZHOU

From the Department of Neurology,West China Hospital of Sichuan University, Chengdu, China
Downloaded by [University of Pennsylvania] at 21:07 05 November 2015

Abstract
Invasive intracranial aspergillosis in immunocompetent patients remains a rarity. We report such a case in a male who
developed symptoms after a dental extraction. Attention should be paid to atypical central nervous system symptoms after
dental procedures; early diagnosis and management are of great importance to improve outcomes.

Introduction pay attention to it. Approximately 20 days before

Invasive intracranial aspergillosis remains a disease
with high morbidity and mortality. Early diagnosis of
this disease requires a high degree of clinical suspi-
cion because there are no typical clinical symptoms
or central nervous system (CNS) findings [1]. CNS
aspergillosis has been reported mainly in immuno-
compromised patients, but it can also affect immu-
nocompetent individuals, especially when there are
risk factors present [2–5]. Although it is a curable
disease, delays in diagnosis and treatment may lead
to devastating outcomes.
Case report
A 56-y-old man was admitted to our department
with left facial pain and frontotemporal headaches of
10-month duration, and worsening symptoms for
approximately 20 days. Ten months previously, the
patient had had his left maxillary wisdom tooth
extracted because food got stuck between the teeth.
After this he experienced a wound infection, and
bone sequestrum was removed. Meanwhile he devel-
oped intermittent left facial pain and frontotemporal
headaches; the pain had persisted since then. Nine
months previously the patient had undergone cranial
magnetic resonance imaging (MRI) which had
revealed ethmoid sinusitis (Figure 1), but he did not
admission his pain had worsened and he had also
developed nasal obstruction with a yellowish dis-
charge, decreased left visual acuity and diplopia.
The patient worked as a civil servant and denied
any contact with rotten plants, etc. He had previously
been in good health and did not have diabetes or an
underlying malignancy, was not taking immunosup-
pressants, and did not have chronic liver disease or
alcoholism. His vital signs were stable. A neurological
examination upon admission revealed involvement of
cranial nerves II, III, IV, V (all three divisions), and
VI. His haematological examination was within nor-
mal limits, and a human immunodeficiency virus
(HIV) test was negative. Cell immunological and
humoral immunological tests were normal. Chest
computed tomography (CT) was unremarkable.
Cranial MRI demonstrated lesions of high signal
intensity on T1-weighted and T2-weighted images in
the left maxillary sinus, sphenoid sinus, ethmoidal
sinus, inter-orbital space, cavernous sinus and tem-
poral lobe (Figure 2). Histopathological staining of
sections of sphenoid sinus tissue (obtained by endos-
copy via nasal cavity) showed characteristic angular
dichotomously branching septate hyphae, indicating
an Aspergillus infection.
The patient was started on voriconazole (200 mg
every 12 h intravenous (IV) infusion) for 21 days, fol-
lowed by caspofungin (50 mg once daily IV infusion)

Correspondence: Zhou Dong, Department of Neurology, West China Hospital of Sichuan University, No.37 Guo Xue Xiang, Wu Hou District, Chengdu
610041, China. Tel: ⫹86 139 8000 8088. Fax: ⫹86 28 8542 2893. E-mail address: zhoudong66@yahoo.de

(Received 18 July 2010 ; accepted 23 September 2010 )

ISSN 0036-5548 print/ISSN 1651-1980 online © 2011 Informa Healthcare
DOI: 10.3109/00365548.2010.527858

Downloaded by [University of Pennsylvania] at 21:07 05 November 2015
Figure 1. Cranial MRI taken 1 month after the dental extraction,
showing areas of hyperintense signal on T2-weighted images
indicating ethmoidal sinusitis.
for 17 days. However the lesions shown on MRI
remained the same and the patient experienced more
severe headaches than before. He was then given
combination therapy of intravenous voriconazole and
liposomal amphotericin B (60 mg once daily IV
infusion) for 74 days. After this he received oral
Figure 2. The patient’s T2-weighted MRI scan taken 10 months
after dental extraction, showing lesions of high signal intensity in
the ethmoidal sinus and temporal lobe (arrow).
Invasive intracranial aspergillosis 157
voriconazole and was discharged. However the
patient’s condition continued to deteriorate. Four
months later he gradually became lethargic and pre-
sented with symptoms of increased intracranial pres-
sure. MRI showed the lesions in his brain had
enlarged. A neurosurgeon was consulted and the
mass in his skull base was resected via a transcranial
base approach. Antifungal agents were administered
pre- and post-operation. Despite the aggressive treat-
ment, the patient went into a deep coma and died
20 days after surgery.
Discussion
Invasive aspergillosis occurs most commonly in
immunocompromised hosts, and in these cases is
most serious and ultimately fatal. There have only
been a few reports on this infection in non-immuno-
compromised patients [2–5]. Aspergillosis in the
CNS is usually secondary to infections elsewhere
in the body, mainly in the lungs, occurring by hae-
matogenous spread; occasionally it may derive from
direct extension of an infection of the sinuses [1,5].
Risk factors for invasive aspergillosis include diabetes,
underlying malignancy, organ transplant, administra-
tion of immunosuppressants, chronic liver disease,
and alcoholism [1–3]. Cerebral invasive aspergillosis
of odontogenic origin in an immunocompetent
man is rarely seen. In our case, since the patient had
previously been healthy, did not have lung involve-
ment or any risk factors and his symptoms developed
immediately after an oral procedure, an odontogenic
origin of the intracranial aspergillosis was considered.
The pathogen probably first intruded into the para-
nasal sinuses from the oral cavity, then extended to
the left fossa pterygopalatina, ethmoidal sinus,
sphenoid sinus, petrous apex and cavernous sinus.
Eventually the brain was involved. By repeated MRI,
the route of spread of the infection was completely
identified. Biopsy confirmed the diagnosis of intrac-
ranial aspergillosis.
Diagnosis of CNS aspergillosis is difficult because
the clinical manifestations are non-specific. The most
common symptoms include persistent fever, focal
neurological deficits, changes in mental status, sei-
zures and headache; nausea and vomiting do not
necessarily occur [1]. Apart from other complaints it
may cause non-typical facial and tooth pain if it is of
odontogenic origin [6]. In our case the patient expe-
rienced facial pain and headache at the beginning of
the disease; disturbed mental status and emesis did
not occur until the end stage. The appearance of
intracranial aspergillosis on CT or MRI depends on
the patient’s immune defence status as well as
the age of the lesions [1]. In immunocompromised
patients, brain lesions that are hypodense with little
 158 B. Yan et al.
mass effect and minimal contrast enhancement on
CT and MRI scans or exhibit isointensive to low
signal intensity on T2-weighted images may suggest
CNS aspergillosis. However in patients without
immunosuppression, lesions with ring or nodular
enhancement on contrast-enhanced T1-weighted
images are typically seen. In the present case, high
signal intensity on T1-weighted and T2-weighted
images were seen. Cerebral lesions in CNS aspergil-
losis are often located not only in the cerebral hemi-
spheres but also in the basal ganglia, thalami, corpus
callosum and perforator artery territories [1]. Cul-
ture and fungal-specific stains such as Gomori’s
methenamine silver stain (GMS) and periodic acid-
Schiff (PAS) are the most commonly used tools to
diagnose invasive aspergillosis. The detection of
Downloaded by [University of Pennsylvania] at 21:07 05 November 2015
Aspergillus galactomannan in the cerebrospinal fluid
may be diagnostic of CNS aspergillosis [1,7].
With respect to treatment of invasive aspergillo-
sis, recent guidelines recommend voriconazole as the
primary choice in most patients. For those whose
aspergillosis is refractory to voriconazole, an ampho-
tericin B formulation or an echinocandin such as
caspofungin or a combination of agents is recom-
mended. High-dose systemic antifungal therapy is
recommended to achieve higher parenchymal con-
centrations [8]. However an intracranial aspergilloma
of the CNS is often refractory to these therapies.
Whenever feasible, a neurosurgical intervention
should be attempted in addition to medical treat-
ment; surgical resection of lesions may prevent seri-
ous sequelae and improve outcomes [1,8]. However,
early initiation of treatment is crucial. For one thing
the concentrations of antifungal agents in the brain
are extremely low compared with those in the blood.
Also, the optimal neurosurgical procedure for CNS
aspergillosis has not been well defined and may
depend on the size and localization of the fungal
brain abscesses. If treatment is delayed it is very dif-
ficult to control an Aspergillus infection. In our case,
patient management did not start until 10 months
after the onset of his symptoms, and even though
aggressive therapy with antifungal agents and abscess
resection were carried out, he still died.
In conclusion, invasive intracranial aspergillosis
can occur in immunocompetent individuals, espe-
cially when there are predisposing factors such as
dental procedures. Clinicians should be cautious
with any CNS complaints and consider the possibil-
ity of invasive cerebral aspergillosis in patients with
signs of sinusitis and a history of oral operation,
regardless of their immune condition. Early diagnosis
and initiation of antifungal therapy are critical for
improving outcomes.
Declaration of interest: No conflicting interest.
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