A rare case of cerebral aspergillus aneurysm at the site of temporary clip application

Anterior communicating artery aneurysm was shown in a 48-year-old man who had suffered from subarachnoid hemorrhage (SAH) by cerebral angiography. Right pterional approach was performed on the 40th day after SAH. Premature ruptured occurred during aneurysmal manipulation and temporary clip (Scoville clip) was placed at the middle of the right A1 segment for fifteen minutes. the anterior communicating artery aneurysm was successfully clipped and postoperative course was uneventful. But, four days after the operation, the patient fell into coma following generalized tonic convulsion. Lumbar puncture showed fresh SAH. Consciousness recovered gradually to a lethargic state. A newly formed berry aneurysm was revealed on the righ A1 segment at the site of the temporary clip application by cerebral angiography performed on the seventh day after aneurysmal surgery. Second attack occurred on the 12th postoperative day and the patient died on the 16th day after the operation. Postmortem findings disclosed massive subarachnoid and intraventricular hemorrhage from the ruptured aneurysm at the right A1 segment. Microscopic examination of the aneurysm and the right A1 segment. microscopic examination of the aneurysm and the right A1 segment showed the extensive destruction of the artery and massive proliferation of aspergillus in the arterial wall which was prominent of its outer layer. The mechanism of the formation of the new aneurysm in this case was considered as follows: the arterial wall was primarily damaged by the temporary clip and was weakened rapidly by the invasion of aspergillus, probably producing thrombosis of the vast vasorum, hemorrhage, and necrosis in it.     

Aspergillotic cerebral arterial aneurysm formation complicating hemodialysis

Formation of an intracranial aneurysm as a result of aspergillus infection, a rare occurrence, typically develops in patients who have not received immunosuppressive therapy but on whom an operation has been performed in the recent past. This report describes the first instance of formation of an aspergillotic cerebral arterial aneurysm in a patient on chronic hemodialysis, which occurred in the absence of a prior operation or immunosuppressive therapy.     

Abscess-forming and necrotizing aspergillus myocarditis in a surgical intensive care patient--a rare occurrence

The case of an 89 year old patient is reported, in whom an aspergillus myocarditis was unexpectedly found at autopsy. Preoperatively, the patient showed no risk factors for an invasive mycosis. 5 days after uncomplicated surgery he developed septic shock due to peritonitis. After surgery and intensive care therapy the patient recovered initially. 23 days after the first operation the patient suddenly developed catecholamin-resistant myocardial failure and died. Ten days before, aspergillus spec. was found in a specimen of bronchial secretion. This finding was interpreted as colonisation and not treated.     

Aspergillus aortitis: a cause for aortic perforation in a patient following combined aortic valve surgery and liver transplantation

We report a case of aspergillus fumigatus aortitis in a patient following combined aortic valve replacement and orthotopic liver transplantation for significant aortic stenosis and alcoholic liver cirrhosis. At operation, a suspicious excavating lesion was found on the native aortic valve and specimen sent for culture. The ascending aorta and aortic sinuses were found to be normal. Routine immunosuppression was commenced post transplant. Urgent valve microscopy was highly suspicious of fungal growth, and antifungal therapy was instituted. Day 18 post-surgery the patient unexpectedly arrested. Post mortem findings showed ascending aortic perforation with multiple fungal lesions noted. Microscopy demonstrated aspergillus fumigatus invading the aortic wall. This is the first case report illustrating a dormant phase of aspergillus fumigatus endocarditis that was activated following surgery and immunosuppression leading to aortitis and subsequent perforation.     

Rapid Development of Bilateral Internal Carotid Artery Aneurysm from Sphenoid Sinus Aspergillosis

The purpose of this case report is to familiarize the sinus surgeon with the possibility of the rapid development of internal carotid artery aneuryams from fungal infections of the sphenoid sinuses. A renal dialysis patient with progressive loss of vision was treated with high doses of steroids for the presumed diagnosis of temporal arteritis. Subsequent work-up included a magnetic resonance arteriogram (MRA) and computed tomography (CT) with contrast that failed to demonstrate aneurysmal changes of the carotid arteries but suggested the presence of a mycotic infection of the sphenoid sinuses. During a sphenoidotomy two days later, in addition to the anticipated aspergillus infection of the sinuses, an aneurysm extending from the left internal carotid artery into the sphenoid sinus was encountered. An emergency arteriogram immediately following the surgery revealed a second newly developed large mycotic aneurysm of the right internal carotid artery filling the right sphenoid sinus as well. This case report documents the rapidity with which mycotic aneurysms can develop from a sphenoid sinus infection secondary to aspergillosis in an immunocompromised host.     

Rapid development of bilateral internal carotid artery aneurysm from sphenoid sinus aspergillosis

The purpose of this case report is to familiarize the sinus surgeon with the possibility of the rapid development of internal carotid artery aneuryams from fungal infections of the sphenoid sinuses. A renal dialysis patient with progressive loss of vision was treated with high doses of steroids for the presumed diagnosis of temporal arteritis. Subsequent work-up included a magnetic resonance arteriogram (MRA) and computed tomography (CT) with contrast that failed to demonstrate aneurysmal changes of the carotid arteries but suggested the presence of a mycotic infection of the sphenoid sinuses. During a sphenoidotomy two days later, in addition to the anticipated aspergillus infection of the sinuses, an aneurysm extending from the left internal carotid artery into the sphenoid sinus was encountered. An emergency arteriogram immediately following the surgery revealed a second newly developed large mycotic aneurysm of the right internal carotid artery filling the right sphenoid sinus as well. This case report documents the rapidity with which mycotic aneurysms can develop from a sphenoid sinus infection secondary to aspergillosis in an immunocompromised host.     

A case report of aspergillus granuloma in the cavernous sinus

We encountered a case of aspergillus granuloma in the cavernous sinus originating in the left sphenoid sinus. The patient was a 56-year-old woman who complained of visual loss and cavernous sinus syndrome on the left side. Hematological data were within normal limits. Bone CT showed evidence of bone destruction in the roof of the left sphenoid sinus. MR images with gadolinium demonstrated an enhanced heterogeneous mass extending from the left sphenoid sinus to the cavernous sinus and the orbital apex. Angiography showed occlusion of the left internal carotid artery. Dexamethasone was administered intravenously every day, because the patient was diagnosed as having Tolosa-Hunt syndrome (THS). However, dexamethasone was not effective. We carried out a biopsy of the mass from the sphenoid sinus, and findings showed aspergillosis. On the 19th day after initiation of fluconazole treatment, the patient lapsed into unconsciousness and presented left hemiparesis. T2-weighted MR images showed high intensity areas in the pons and the thalamus. The patient died two days later. An autopsy revealed edema and many infarctions throughout the brain. The cavernous sinus had been replaced completely with aspergillus granuloma. Furthermore, numerous hyphae of aspergillus had adhered to the inside of the basilar artery, and caused occlusions of arteries around the brain. This case indicated the difficulty of diagnosis of THS and the hazard of over-application of steroids. In this paper, we describe the clinical and pathological behavior of aspergillosis in the cavernous sinus.     

Renal Allograft Aspergillus Infection Presenting With Obstructive Uropathy: A Case Report

Background

Isolated renal allograft aspergillosis is rare and usually presents with fever and decreased glomerular filtration rate. Presentation with obstructive uropathy caused by aspergillus fungal balls is much less common. We report a young male patient who presented with obstructive uropathy secondary to isolated renal allograft aspergillus infection 6 weeks after transplant. He was treated with nephrectomy and antifungal medications.

Spinal aspergillosis in nonimmunocompromised host mimicking Pott’s paraplegia

The aim of this report is to highlight the less-known aspergillus spondylitis (AS) that may completely mimic Pott's paraplegia, leading to occasional but expensive diagnostic error, as the chemotherapeutic management of the two is different. A case of a patient with the diagnosis of Pott's paraplegia who turned out to have aspergillus spondylitis is described. Issues and difficulties regarding the differentiation between these two forms of spine infection and their therapeutic implications are discussed. We conclude that differential diagnosis of spinal tuberculosis (TB) should include aspergillus spondylitis, as cure of spinal aspergillosis, especially in early stages, is possible with surgery and/or antifungal agents, and morbidity and mortality are high in neglected cases.     

Fatal rupture of a thrombosed giant basilar artery aneurysm

The case of a patient who died from rupture of an aneurysm that had previously been demonstrated to be essentially completely thrombosed is presented. The patient initially presented with sudden clinical deterioration as a result of brainstem compression. A computed tomographic scan showed a giant basilar aneurysm with recent thrombus filling the lumen. Angiography showed only a small irregularity at the top of the basilar artery which may have represented a tiny remnant of the aneurysmal neck. The patient was treated conservatively, and over the next few weeks he improved clinically. Four months later the aneurysm ruptured fatally.     

Pulmonary aspergillus infection invading the pleura.

During a 10-year-period, six patients with non-postoperative aspergillus infection of the pleura were seen. In all patients a pulmonary aspergillus infection had been present for some years. The fungus invaded the pleura, causing a bronchopleural fistula and a cavity in the pleural space. A prerequisite for the pleural aspergillosis was that the lung and pleura were previously damaged, usually by therapeutic pneumothorax for active tuberculosis some decades earlier. The fungus can cause destruction of the lung and death of the patient from the chronic infection unless treated. The best treatment is early excision of the pleura with resection of the upper lobe or if necessary the whole lung. To reduce the risk of postoperative aspergillus empyema, the patient should be treated with antifungal agents before and after operation. In inoperable patients, local antifungal treatment may clear the infection but is not always effective.     

Primary Aspergillus endocarditis. Apropos of a case and review of the international literature]

The authors report a case of primary aspergillus endocarditis with endophthalmitis and vertebral osteomyelitis. No underlying disease and no predisposing factors were found. Valve replacement plus combined antifungal chemotherapy proved to be effective as the patient is asymptomatic 18 months after the first symptoms. 48 cases of aspergillus endocarditis, without prior cardiac surgery have been reported in the literature. Aspergillus endocarditis was valvular or mural. Extracardiac dissemination was common but endophthalmitis and osteomyelitis were infrequent. In 11 cases, the diagnosis was made by histologic examination of embolectomy or ocular, skin biopsy tissue. All patients were febrile. Blood cultures showed no Aspergillus species. Clinical manifestations of endocarditis were described in less than fifty per cent of cases. Echocardiographic visualization of vegetations was obtained in 5 cases. Many patients experienced embolic phenomena. Mortality from Aspergillus endocarditis is extremely high (96%). Surgery is the main treatment, consisting of valve replacement. Antifungal chemotherapy should be combined. The proper duration and dosage and the combination of antifungal drugs have not been clearly defined.     

An operated case report of pulmonary aspergillosis by sapprophytic infection of Aspergillus candidus in congenital bronchial cyst of right lower lobe

Aspergillosis is a mycotic disease caused by a variety of species of the dimorphic fungus aspergillosis, especially aspergillus fumigatus. But the report of pulmonary aspergillosis by aspergillus candidus is very rare. We experienced a surgical case of pulmonary aspergillosis caused by aspergillus candidus. The patient is a 18-year-old girl. Eleven years ago, she had suffered from pneumonia of rt. lower lobe, there after she often has suffered from cough and fever every year. In 1986, chest x-ray photography shows a small cavity in rt. lower lobe. In 1989, it becomes a big cavity of 8 X 8 cm in diameter with niveau. She has cough and bloody sputum of 100-150 ml daily. We have cultured aspergillus candidus from sputum, bloody pus obtained by percutaneous aspiration needle lung biopsy of the cavity and bloody pus in the cavity which was resected on March 3, 1989. But the pathological investigation could not demonstrate any fungus ball or fungus body of aspergillus candidus.     

Aspergillus mycotic aneurysm--case report.

A 61-year-old female developed subarachnoid hemorrhage after trans-sphenoidal surgery for Rathke's cleft cyst. Neuroradiological examination revealed a large aneurysm at the C1 portion of the right internal carotid artery. Autopsy revealed marked proliferation of aspergillus hyphae in the wall of the aneurysm. A review of previously reported cases of fungal aneurysm proposes two developmental processes. Aneurysms secondary to fungal meningitis tend to be large in size and located in the major cerebral artery trunk, but aneurysms following fungal sepsis tend to be small and in peripheral branches. The former aneurysms are probably caused by fungus invasion into the intracranium, usually from the paranasal sinus, and the latter may be due to fungal emboli like bacterial emboli in bacterial endocarditis. Ruptured fungal aneurysms are difficult to treat, so fungal meningitis or sepsis must be eradicated before an aneurysm develops.     

Diagnosis and management of aneurysms involving the superior mesenteric artery and its branches--a report of four cases

Aneurysms of the superior mesenteric artery (SMA) are an uncommon but lethal entity, which must be treated expeditiously to avoid mortality and high incidence of ischemic small bowel complications. In the past 7 years the authors have treated 4 patients with a variety of types of aneurysms involving the SMA and its branches at a university-based teaching hospital. The first was a mycotic SMA aneurysm as a result of septic mitral valve, the second a jejunal aneurysm in a patient with pancreatitis, the third a spontaneous dissection distal to a small SMA aneurysm with thrombus partially occluding the distal vessel, and the fourth an SMA aneurysm associated with the diagnosis of mesenteric insufficiency. All patients presented with abdominal pain. The diagnosis was made initially in 1 patient on plain abdominal films with a calcified aneurysm, on duplex scan in the second, and on computed tomography (CT) scans in the remaining 2. Treatment consisted of bowel resection and ligation of mycotic aneurysm in the first patient, of catheter embolization of jejunal aneurysm in the patient with pancreatitis, and of vein graft bypass in the patient with a large SMA aneurysm. The patient with SMA aneurysm and distal dissection with partially occluding thrombus received anticoagulation and is being followed up with serial CT scans. There were no deaths. One patient required bowel resection, which did not result in short gut syndrome. Improved abdominal duplex scanning and CT technology facilitates the diagnosis of mesenteric aneurysm. The broad spectrum of etiologies mandates that treatment be tailored to the individual patient, and it varies from endovascular techniques to traditional bypass surgery. Prompt diagnosis and treatment results in the lowest mortality rate and minimizes the prevalence of intestinal infarction.     

Ruptured middle cerebral artery aneurysm successfully treated by intra-aneurysmal GDC embolization in a patient with idiopathic thrombocytopenic purpura: a case report]

We report a case of a ruptured middle cerebral artery (MCA) aneurysm treated by an intra-aneurysmal Guglielmi detachable coil (GDC) embolization in a patient with idiopathic thrombocytopenic purpura (ITP). A 57-year-old female, who had been suffering from ITP for 4 years, experienced sudden severe headache. She was diagnosed as having subarachnoid hemorrhage due to a ruptured MCA aneurysm and the hematological examination showed moderate thrombocytopenia. Considering the risk of open surgery, we treated the aneurysm by intra-aneurysmal GDC embolization in the acute stage and platelet transfusion was carried out after the therapy. She had a good clinical course and recovered without any complications or neurological symptoms. The follow-up cerebral angiogram at 1 week and 2 years after the treatment showed complete obliteration of the aneurysm. Recently, endovascular treatment tends to be applied to surgically high-risk patients. A GDC embolization for a patient with thrombocytopenia has rarely been reported and the risk and efficacy is unknown. So, we conclude that for a patient with thrombocytopenia, intra-aneurysmal GDC embolization could be adopted as one of the less invasive treatment for ruptured aneurysm.     

Dissecting aneurysm of the middle cerebral artery manifesting as subarachnoid hemorrhage and hemorrhagic infarctions--case report

A 46-year-old woman presented with a dissecting aneurysm of the right middle cerebral artery manifesting as subarachnoid hemorrhage followed by hemorrhagic infarctions. The aneurysm was clipped and wrapped. However, serial angiography showed progression of the lesion, which was probably responsible for the clinical course of this patient. Intracranial dissecting aneurysms are less common, and the natural history of these lesions is unclear. Conservative management might be preferable in this patient.     

A case of extravasation from a cerebral aneurysm during 3-dimensional computed tomography angiography

BACKGROUND: Reports of rebleeding from an aneurysm during 3D-CTA are rare because this imaging method is not widely available. In previous cases, rebleeding of the aneurysm presented with certain imaging features, which were cap-like, corkscrew-like, ribbon-like, and nebulous areas of enhancement. We had a patient whose aneurysm had reruptured during 3D-CTA. This is the sixth report. CASE DESCRIPTION: The patient came to our hospital with SAH. A 3D-CTA showed a pooling of contrast medium in the temporal parenchyma and an aneurysm with an irregular bleb at the bifurcation of the right MCA. The aneurysm with bleb seemed to have a daughter aneurysm and a granddaughter aneurysm, which attached on the daughter aneurysm. We diagnosed rerupture during 3D-CTA because of a clear difference between the initial CT scan and those used as source data for 3D-CTA. Intraoperatively, we confirmed that a part of the aneurysm invaginated into the temporal lobe and that the possible granddaughter aneurysm was a clot on the daughter aneurysm. The intraparenchymal hematoma was attached to this clot. CONCLUSIONS: We report a patient with rerupture of a cerebral aneurysm during 3D-CTA showing new pattern in the image. When extravasation of blood occurs into the brain parenchyma, 3D-CTA clearly demonstrates its extent because there is little attenuation by CSF. In such cases, extravasated blood can form both a small mass that mimics a granddaughter aneurysm and a pooling of contrast medium.     

Endovascular conversion with femorofemoral bypass as a treatment of endotension and aneurysm sac enlargement

We report a case of a patient treated with a Gore Excluder endograft for AAA in November 2003 with subsequent aneurysm sac enlargement in the absence of an identified endoleak. The patient had a Type I endoleak treated with a Palmaz stent at the neck and later developed a Type II endoleak treated with translumbar coil embolization. This was successful with absence of pressure in the sac after the procedure and stable aneurysm size over the next nine months. Surveillance of the patient with both CT and ultrasound then revealed an increase in the aortic sac diameter in the absence of endoleak. A Cook Zenith converter was used to reline this PTFE endograft. Subsequently, imaging showed aneurysm sac shrinkage. This is a report of endotension with aneurysm expansion following Gore Excluder placement which was treated successfully with a dacron endograft.     

Successful treatment of an aortoesophageal fistula after emergency endovascular thoracic aortic stent-graft placement

We report the case of a 57-year-old man who underwent emergency stent-graft placement in August 2003 due to a contained rupture of a distal descending aortic aneurysm. After 1 month the patient was readmitted with chest pain as well as swallowing disorders. A computed tomographic scan revealed a fistula between the distal esophagus and the excluded aneurysm sac. The patient was treated by an esophagectomy, a cervical esophagostomy, as well as a feeding gastrostomy. The infectious parietal thrombus was partially debrided and the aneurysm sac was filled with vancomycin. After 3 months continuity was reinstalled with a pedicled isoperistaltic transverse colonic conduit. The patient recovered uneventfully. At a 3 month follow-up, he showed no signs of infection. However, he is still being treated with antibiotic therapy of ciprofloxacin for a minimum of 1 year.