Unusual complications of bone wax at the skull base

Objective This study aimed to describe the clinical presentation, microbiological profile and management of complications of bone wax usage for surgical procedures at the skull base. Method The case records of a series of five patients who developed post-operative surgical site complications because of bone wax usage during skull base surgery were reviewed. Results In all five patients, persistent site-specific clinical features were noted along with intra-operative presence of excessive bone wax. Three unique cases of presentation, one with a fungal brain abscess because of Aspergillus flavus infection, another with fungal osteomyelitis because of Trichosporon beigelii infection and a third with intradural migration of bone wax into the cerebellopontine angle cistern are highlighted. Conclusion The presentation of surgical site infection at the skull base because of excessive use of bone wax can be manifold. The need for testing appropriate cultures including fungal culture is highlighted.

Cerebral Aspergilloma in Patient with Diabetes – A Case Report with Short Literature Review

BACKGROUND: In the recent years, the incidence of fungal brain abscess has been rising as a result of the increased use of corticosteroid therapy, broad-spectrum antimicrobial therapy, and immunosuppressive agents. Aspergillosis of the central nervous system (CNS) is reported in 10%–20% of the patients having invasive fungal disease. Commonly, the disease is observed in immunocompromised or immunosuppressed patients; also, patients who suffered traumatic head injury are reported as well to develop the infection due to due cranial defect accompanied by dural tearing. Symptoms are non-specific neurologic manifestations. CASE PRESENTATION: We presented a case of a 68-year-old man who had diabetes mellitus type II. He was admitted to in neurosurgery clinic due reported head trauma. Initially, he complained of a headache, dizziness, slurred speech, nausea, and pain in the right ear with tinnitus and pain in his right upper teeth – continuous for a month. The patient was conscious, adequate, Glasgow Coma Scale – 15 points, with left-sided hemiparesis, general symptomatic syndrome. An emergent computed tomography scan was performed, which showed tumorous formation in patient’s right temporal lobe that had mass effect and compression of the right lateral ventricle. The patient was discussed on a emergent clinical counsel and it was decided that he was shown for surgical treatment. An informed consent was signed by the patient and his relatives. After the surgery intervention – the histological result of the biopsy was aspergilloma of the brain and the microbiological result was Aspergillus fumigatus. CONCLUSION: The prognosis for CNS aspergillosis is poor, but the early diagnosis and effective medical and surgical treatments may reduce morbidity and mortality.

Cerebral Phaeohyphomycosis: A Rare Case from South India

Background and Importance: Cerebral phaeohyphomycosis is a rare but frequently fatal clinical entity caused by dematiaceous fungi like Cladophialophora bantiana. Fungal brain abscess often presents with subtle clinical symptoms and signs, and present diagnostic dilemma due to its imaging appearance that may be indistinguishable from other intracranial space-occupying lesions. Still, certain imaging patterns on Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) help to narrow down the differential diagnosis and initiate prompt treatment of these infections. Case Presentation: A 48-year-old immunocompetent man presented with right-sided hemiparesis and hemisensory loss and a provisional diagnosis of stroke was made. The radiological evaluation suggested the possibility of a cerebral abscess. Accordingly, surgical excision of the lesion was performed and the histopathological examination of the specimen revealed the etiology as phaeohyphomycosis. The patient was further treated with antifungals and discharged when general conditions improved. Conclusion: Fungal Central Nervous System (CNS) infections present diagnostic challenges and should be considered while interpreting ring-enhancing CNS lesions in immunocompetent patients. Surgical resection and antifungal treatment should be considered in all patients with cerebral phaeohyphomycosis.

1411. Differentiation of Fungal Abscess of Brain From Brain Glioblastoma by MRI Scan ADC Value

Background Differentiation of Brain fungal abscess from brain glioblastoma is very important. Treatment strategies are different in both cases. Glioblastoma needs different surgical planning as compared with abscess. We hypothesized that preoperative MRI brain will help in differentiation. Methods A retrospective study was carried out at Aga Khan University Hospital Karachi. Data from 2007 to 2017 was retrieved from Medical records using ICD-9 coding. 90 patients (47 males and 43 females; age range 10–70 years) with aggressive grade IV brain lesion and fungal abscess was selected and their preoperative MRI data were retrieved. The apparent diffusion coefficient (ADC) maps were reconstructed from diffusion-weighted imaging DWI data. The mean ADC value and standard deviation of glioblastoma and fungal abscesses were calculated. Postoperative biopsy results were used as gold standard.The analysis of data was done to test statistically significant differences between glioblastoma and fungal brain abscess. Receiver operating characteristic (ROC) curve was used to determine the cut-off point with highest accuracy that was used to differentiate malignancy from infection. The statistical analysis of data was done using SPSS® v. 19. Results The mean (±standard deviation) ADC value of fungal brain abscess (826.040 ± 94.97 × 0.001 mm2/sec) was significantly lower than that of glioblastoma (1,462.800 ± 163.66 × 0.001 mm2/sec). When an ADC value of 1,200 × 0.001 mm2/s used as a cutoff value for differentiating fungal abscess from glioblastoma the best result was obtained with an accuracy of 85%, sensitivity of 81%, specificity of 88%, negative predictive value of 80%, and positive predictive value of 90%. Conclusion ADC value is a noninvasive promising imaging parameter that can be used for differentiation of fungal brain abscess and glioblastoma on preoperative scan. The cut-off value with best accuracy in our study was 1,200 × 0.001 mm2/s. Disclosures All authors: No reported disclosures.

Fungal Brain Abscess Mimicking High Grade Glioma. Clinical Case

Intracranial brain abscess is a recess of pus in the brain [1]. Abscess may have single or multiple leasions in varies regions of the brain [1-4]. Pus is surrounded by abscess wall or capsule. The most common cause of brain abscess is bacteria, as fungal infection usually occurse in patiens with history of immunosuppression. However half of fungal infection casses, patients had no risk factors, adjacent disease or known immumosuppresion. Fungal brain abscess is rare sourse of brain abscess but frequently fatal and even for patients with no immunosuppresion [4-7]. Infection to the central nervous system spreads in several different ways. Hematogenous path from the lungs, gastrointestinal tract, or directly from the sinuses, orbits and retro-parapharingialy [4]. In this article we present a clinical case, were we first of all suspected brain tumor for the patient but later this diagnosis was denied by histological findings, whitch brought us new diagnosis fungal brain abscess.