amphotericin-b and Carotid-Artery-Diseases

In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .

Topics: Aged; Amphotericin B; Aneurysm, Infected; Antifungal Agents; Carotid Artery Diseases; Carotid Artery, Internal; Embolization, Therapeutic; Female; Humans; Immunocompromised Host; Mucorales; Sphenoid Sinus; Sphenoid Sinusitis; Treatment Outcome

A 59-year-old man with a long history of under-treated diabetes mellitus presented with severe inflammation that had spread from the sinus to the left orbital cavity. The bilateral internal carotid arteries were severely stenotic, causing multiple infarctions in the brain parenchyma. There was no β-D-glucan detected in the cerebrospinal fluid. Based on the presence of central nervous system (CNS) inflammation and vascular involvements that spread from the sinusitis, we tentatively diagnosed this patient as having invasive fungal CNS infection, i.e. zygomycosis or aspergillosis. Although the patient was treated with anti-fungal drugs such as liposomal amphotericin B and voriconazole, he died of respiratory failure. Pathological examination of the autopsied tissues demonstrated zygomycosis in the brain and heart. The prevalence of zygomycosis is generally very low (-5% of CNS infections) compared with that of other fungal infections. The lack of an appropriate diagnostic marker may lead to the under- or mis-diagnosis of zygomycosis. Moreover, it is hard to differentiate zygomycosis from aspergillosis because the two diseases share common clinical features such as the association of sinusitis and vascular involvement. The clinically diagnostic points that discriminate zygomycosis from aspergillosis are as followed; i) β-D-glucan is negative in zygomycosis but positive in aspergillosis; ii) diabetes is more frequent in patients with zygomycosis to those with aspergillosis; iii) the infectious lesion in aspergillosis shows an iso-low-intensity on T(2) weighted MRI image but shows a high intensity lesion in zygomycosis. The mortality rate of CNS zygomycosis is so high that an early diagnosis of it is warranted and the start appropriate anti-fungal treatments or surgical drainage in the early stage of the disease.

Topics: Amphotericin B; Antifungal Agents; Autopsy; Carotid Artery Diseases; Central Nervous System Fungal Infections; Diagnosis, Differential; Humans; Male; Middle Aged; Neuroaspergillosis; Zygomycosis

Topics: Acyclovir; Aged; Amphotericin B; Aneurysm; Aneurysm, Infected; Anti-Infective Agents; Brain Edema; Carotid Artery Diseases; Carotid Artery, Internal; Ceftriaxone; Dexamethasone; Embolization, Therapeutic; Equipment Contamination; Female; Humans; Imaging, Three-Dimensional; Infarction, Middle Cerebral Artery; Magnetic Resonance Imaging; Meningoencephalitis; Prostheses and Implants; Prosthesis-Related Infections; Tomography, X-Ray Computed

We describe a patient who developed Candida albicans brain abscess associated with prominent vascular invasion following an episode of central venous catheter-related fungemia. The increasing population of immunosuppressed patients and the frequent use of broad-spectrum antimicrobials, corticosteroids, chemotherapeutics, organ transplantation, and prolonged supportive measures are responsible for an increasing incidence of candidal infections. Brain abscess is a rare complication of candidemia but may be expected to become more common as venous catheter-related fungemia is encountered more frequently.

Topics: Amphotericin B; Arterial Occlusive Diseases; Brain; Brain Abscess; Candida albicans; Candidiasis; Carotid Artery Diseases; Carotid Artery, Internal; Catheterization, Central Venous; Cerebral Arteries; Craniotomy; Drug Therapy, Combination; Flucytosine; Fungemia; Humans; Magnetic Resonance Angiography; Male; Middle Aged; Tomography, X-Ray Computed

Two fatal cases of rhinocerebral mucormycosis with fungal invasion and occlusion of the internal carotid artery are described. Review of the literature reveals 35 similar cases of whom only 6 survived. Emphasis is placed on the need for early diagnosis and prompt therapy which consists of correction of the underlying disease, aggressive surgical debridement, and amphotericin B.

Topics: Adolescent; Adult; Aged; Amphotericin B; Brain Diseases; Carotid Artery Diseases; Child; Child, Preschool; Debridement; Female; Humans; Infant; Male; Middle Aged; Mucormycosis; Nose Diseases; Orbital Diseases; Paranasal Sinus Diseases

Topics: Amphotericin B; Carotid Artery Diseases; Cranial Sinuses; Eye Manifestations; Gangrene; Geriatrics; Humans; Mucormycosis; Nose; Nystatin; Ophthalmoplegia; Orbit; Paranasal Sinuses; Sinus Thrombosis, Intracranial; Sinusitis