Abstract
Background
Little is known about the natural history of skull base fungal lesions in immunocompetent individuals and the effect of high-dose radiation on fungal lesions.
Method and Results
We report a case where radiosurgery was given to a skull base aspergilloma, mistaking it to be a trigeminal schwannoma. There was dramatic spread of the lesion to periventricular region with significant increase in the skull base lesion. The patient never received steroids. A stereotactic biopsy established the diagnosis, and treatment with voriconazole helped.
Conclusions
It is possible that radiosurgery decreases local immunity due to vascular sclerosis and aids in spread of the fungal lesion, though it is only speculative. This again highlights the importance of establishing the diagnosis prior to radiosurgery.
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References
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Author’s contribution
Kanchan K. Mukherjee
Concept and design, collection and collation of data, manuscript drafting and final approval
Pravinz Salunke
Collection of data, manuscript drafting and final approval
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Comment
I was intrigued to read this curiosity. The authors identified the patient with the radiological diagnosis of trigeminal schwannoma, treated it with radiosurgery and 1 1/2 year later treated him for hydrocephalus. Although culture was negative, they diagnosed meningitis being in the background of the hydrocephalus. The correct diagnosis of fungal meningitis (Aspergillus) was made only after further worsening.
It would be easy to dismiss this case report because of its extreme rarity. Intracranial fungal infections in immune competent individuals are extremely rare at least in the developed world. However, the authors suggest, based on this case, that it is important to establish diagnosis prior radiosurgery. This has to be addressed.
Hundreds of thousands of cases have been treated around the world for benign skull base tumours without histological diagnosis. It would be difficult to justify major neurosurgical interventions in order to arrive to a histological proof of what turns out to be a correct radiological diagnosis in the overwhelming majority. Even if one were to accept that radiation might have contributed to the spread of fungal infection in this case, a very tenuous ‘post hoc ergo propter hoc’ argument based on the effects of radiotherapy, recommending microsurgery instead of the current practice of radiosurgery is difficult to justify. Personally, if I were to encounter their patient with the kind of MRI scan they show in figure 1, unless a very astute radiologist advises me to the contrary, I would treated with radiosurgery. Reading this article will not change my practice.
Andras Kemeny
Sheffield, UK
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Mukherjee, K.K., Salunke, P. Uncontrolled spread following radiosurgery for a skull base aspergilloma misdiagnosed as schwannoma: is radiosurgery responsible?. Acta Neurochir 158, 643–646 (2016). https://doi.org/10.1007/s00701-016-2736-1
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DOI: https://doi.org/10.1007/s00701-016-2736-1