A 63‐year‐old man with no medical history presented with headache (HA) for 2 months. A week after his HA started, he had a normal CT of head. His HA worsened over next 2 months and was associated with intermittent fever, photophobia, vertigo and neck stiffness. He was admitted to OSH and had magnetic resonance imaging (MRI) which was normal but lumbar puncture (LP) showed WBC 345 (66% polys) RBC 35, glucose 56 and Protein 267. Antibiotics were initiated and transferred to our hospital. On exam, he had photophobia, neck stiffness and right eye ptosis. Labs: WBC 15, hemoglobin 10, platelets 449, normal CMP, ESR > 140, CRP 17. Repeat LP showed WBC 13 (16% poly), RBC 16, glucose 59, and protein 79. We stopped all abx as all CSF and blood cultures, viral (including West Nile, CMV, EBV, HSV) and fungal (crypto, histo, blasto, Fungitell ) studies were negative. As he did not improve, we did a repeat MRI in a week, which showed fungal mass in sphenoid sinus. Had left sphenoidectomy. Fungal stain showed fungal hyphae with no tissue or angioinvasion and culture grew Aspergillus fumigatus. Postsurgery his ptosis, hearing loss, and HA resolved. He did not receive any antifungal treatment.
Fungal infections of the nasal cavity and sinuses can range from colonization to invasive fungal sinusitis. Most common causes of fungus ball are immunosuppression, AIDS, DM, and steroid treatment. Most common organism is Aspergillus fumigatus. Patients with acute fungal rhinosinusitis usually present with fever, facial pain, nasal congestion, and epistaxis. Diplopia and meningitis are rare. A high degree of suspicion must be maintained in immunosuppressed patients with sinus complaints and signs of meningitis. If CT scan is negative, we need to consider MRI as it also helps to assess intracranial and cavernous sinus involvement. Diagnosis is by tissue biopsy. As most patients are immunosuppressed, antifungal therapy is indicated in spite of resection. Empiric treatment is with amphotericin but if Aspergillus is isolated, we can switch to voriconazole. Duration of therapy depends on the immune status of the host, the extent of surgical debridement, and the response to therapy. Suppressive therapy is indicated for at least three to six months but may require lifelong if remains immunosuppressed. Our case was unusual as pt was immunocompetent, CSF was abnormal but sterile, initial imaging including MRI were normal and complete resection with free margin led to cure. We did not use antifungal treatment or suppressive therapy.
Fungal ball is common in immunosuppressed but rare in immunocompetent patients. Meningeal involvement can occur but parameningeal irritation with abnormal CSF cell count, sterile CSF culture and normal MRI scan can present a diagnostic challenge. High degree of suspicion, repeat imaging at short interval as in this case can identify the lesion early on and guide treatment and prevent complications.
To cite this abstract:Chuda R, Poddutoori P, Subramaniam D, Anant S. Aseptic Meningitis: Think Outside the Brain. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 469. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/aseptic-meningitis-think-outside-the-brain/. Accessed July 22, 2019.