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Chapter 24 : Sinusitis and Cerebral Aspergillosis

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Abstract:

species are the most frequently identified pathogens in patients with fungal sinusitis. Aspergillosis of the paranasal sinuses virtually always represents an airborne disease, which is acquired by inhalation of conidia. The noninvasive forms of sinusitis are mostly categorized into allergic sinusitis and sinus fungus ball or mycetoma. For antifungal therapy, amphotericin B has been the standard treatment in the past and may continue to be an alternative under resource-limited conditions. Alternatively, itraconazole has been used successfully either alone or in combination therapy with amphotericin B in some studies. In patients with cerebral aspergillosis, symptoms tend to progress rapidly, leading to death within days if untreated. Brain abscess formation is the most frequent finding in patients with cerebral aspergillosis. An altered mental status, focal neurological deficits, and seizures are the most common symptoms reported in patients with cerebral aspergillosis. The blood-cerebrospinal fluid (CSF) barrier comprises mainly the choroidal and arachnoidal epithelium, which is fenestrated and faces the CSF. Although substances may enter more easily into the CSF, further penetration into brain tissue is limited by the ependyma, a single layer of epithelial cells which covers the ventricles. In an open-label clinical trial, treatment responses to oral posaconazole therapy were assessed in a subset of 39 patients with various types of central nervous system (CNS) fungal diseases. The majority of patients had cryptococcal meningitis, and four patients suffered from cerebral aspergillosis. Successful responses to voriconazole treatment with long-term survival were repeatedly reported in single patients with cerebral aspergillosis.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24

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Figures

Image of Figure 1.
Figure 1.

Drawings from the first description of fungal rhinosinusitis, showing a fungal morphology compatible with (Schubert, 1885). Reprinted with permission of Blackwell Publishing.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 2.
Figure 2.

Acute invasive sinusitis () with orbital cellulitis in a patient after hematopoietic stem cell transplantation (see also Color Plate 11). CT scan showing sinusitis with destruction of the medial wall of the right maxillary sinus.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 3.
Figure 3.

Acute invasive fungal sinusitis () resulting in fungal retinitis in a patient after hematopoietic stem cell transplantation (see also Color Plate 12). Magnetic resonance imaging scan (T1-weighted, Gd-enhanced imaging) showing sinusitis of the ethmoidal sinuses with extension into the orbital cavities.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 4.
Figure 4.

Acute invasive sinusitis with orbital cellulitis caused by spp., resulting in palate destruction in a patient with acute leukemia (see also Color Plate 13). The CT scan shows opacification of the right ethmoidal sinus (black arrow) and thickening of periorbital soft tissue (white arrows). Reprinted from the (Schwartz and Thiel, 1997) with permission of the Massachusetts Medical Society.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 5.
Figure 5.

Fungal brain abscess caused by hematogenous spread from invasive pulmonary aspergillosis in a patient after hematopoietic stem cell transplantation. Brain section and histological photographs were kindly provided by A. Harder, Berlin, Germany (see also Color Plate 14). The magnetic resonance imaging scan (fluid-attenuated inversion recovery imaging) shows a brain abscess within the left-sided region of the nucleus caudatus.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 6.
Figure 6.

Acute invasive sinusitis caused by , with continuous intracranial invasion resulting in a brain abscess in a hematopoietic stem cell recipient. Radiographs were generously provided by C. P. Heussel, Heidelberg, Germany. (A) CT scan demonstrating bone destruction (arrow) of the lateral sphenoidal sinus. (B) Magnetic resonance imaging scan (T1-weighted, Gd-enhanced imaging) disclosing sphenoidal infiltration (black arrow) and adjacent temporal lobe abscess formation (white arrows).

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Image of Figure 7.
Figure 7.

Survival curve for 81 patients with proven or probable cerebral aspergillosis treated with primary or salvage vori-conazole therapy (Schwartz et al., 2005). This research was originally published in the journal and is reprinted here with the permission of the American Society of Hematology.

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
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Tables

Generic image for table
Table 1.

Clinicopathological subtypes of sinusitis

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24
Generic image for table
Table 2.

CSF and brain tissue levels of selected antifungal drugs

Citation: Schwartz S, Ruhnke M. 2009. Sinusitis and Cerebral Aspergillosis, p 301-317. In Latgé J, Steinbach W (ed), and Aspergillosis. ASM Press, Washington, DC. doi: 10.1128/9781555815523.ch24

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