Clinical Picture
Rhinocerebral aspergillosis
Manjul Tripathi, Sandeep Mohindra
A 27-year-old man presented to our hospital with a
4-month history of bilateral frontal headache, irritability,
frontal lobe signs, bilateral proptosis, and nasal
obstruction. He had no other signs or symptoms of a
systemic illness. Rhinoscopy showed a soft tissue mass
obstructing both nasal airways. A CT scan of his head
showed hyperdense lesions involving both the paranasal
sinuses (figure), with expansions into the frontal
interdiploë spaces, and some calcification (figure). An
MRI scan of the brain showed a soft tissue mass
extending along the anterior cranial fossa floor up to the
sellar and parasellar regions (figure). Endoscopic biopsy
was inconclusive; however, because of raised intracranial
pressure, the patient was taken to surgery for craniotomy
and excision of the lesion.
During the operation, an extradural grey-coloured,
foul smelling, soft tissue mass was seen carpeting the
cranial fossa floor over both frontal lobes and extending
up into the air sinuses. The extradural mass, which
was found to be exerting pressure on the brain by
compressing the frontal lobes without any macro­
scopic invasion of the dura, was excised completely.
The intracranial pressure was reduced on completion
of the operation.
A C
Figure: Aspergillosis in the nose and brain
CT scan shows pansinusitis (A) and specifically both frontal sinuses with calcification in the lesions (B). T2-weighted MRI image shows hypointense lesion in frontal
sinus (C).
www.thelancet.com Vol 392 September 8, 2018 e8
Histopathological examination of the lesion showed Lancet 2018; 392: e8
septate fungal hyphae most consistent with Aspergillus Department of Neurosurgery,
spp. Post Graduate Institute of
Medical Education and
In the immediate postoperative period, the patient was
Research, Chandigarh, India
conscious and had no additional neurological deficits; he (M Tripathi MCh,
was also started on voriconazole. However, 24 h post- S Mohindra MCh)
operatively, the patient suddenly became unresponsive Correspondence to:
and needed mechanical ventilation. He remained uncon­ Dr Manjul Tripathi, Department
of Neurosurgery, Neurosurgery
scious and on the fourth day after the operation, he
Office, 5th Floor Nehru Hospital,
developed diffuse ischaemic changes—possible global Post Graduate Institute of
ischaemia—throughout the brain and died. Medical Education and Research,
Unexpected deaths have been widely reported in cases Chandigarh 160012, India
drmanjultripathi@gmail.com
of intracranial aspergillosis, but sudden deterioration
on the first postoperative day is unusual. Systemic
antifungal chemotherapy should be started prior to any
surgical intervention. Such clinical and radiological
presentations will, in our opinion, continue taking even
the most experienced clinicians by surprise.
Contributors
We both cared for and managed the patient. MT designed the paper,
reviewed the literature, analysed and collected data, and provided
administrative support. SM supervised writing of the manuscript. Written
consent for publication was obtained from the patient’s next of kin.
© 2018 Elsevier Ltd. All rights reserved.