- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
- Department of Microbiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
Sunkara Srikanth Reddy
Department of Microbiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
DOI:10.4103/2152-7806.128183Copyright: © 2014 Reddy SS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Reddy SS, Penmmaiah DC, Rajesh A, Patil M. Orbital tuberculosis with coexisting fungal (Aspergillus flavus) infection. Surg Neurol Int 04-Mar-2014;5:32
How to cite this URL: Reddy SS, Penmmaiah DC, Rajesh A, Patil M. Orbital tuberculosis with coexisting fungal (Aspergillus flavus) infection. Surg Neurol Int 04-Mar-2014;5:32. Available from: http://sni.wpengine.com/surgicalint_articles/orbital-tuberculosis-with-coexisting-fungal-aspergillus-flavus-infection/
Background:A coexisting invasive fungal and tubercular involvement of the skull base is a rare event. Co-infection has been reported with involvement of paranasal sinuses and middle ear cleft.
Case Description:We herein report a case of an elderly male diabetic patient who presented with gradually progressive visual loss, which on imaging showed an orbital lesion. Surgical decompression and microbiological evaluation showed growth of Mycobacterium tuberculosis and Aspergillus flavus.
Conclusion:Rare combinations of such infections do exist and should be treated aggressively to achieve good outcomes in a losing battle with fastidious organisms in the backdrop of compromised immunity.
Keywords: Aspergillus, co-infection, fungal, granuloma, orbital, skull base, tuberculosis
Orbital lesions, pose a challenge as there are many mimics and imaging alone is not sufficient to diagnose the problem at large. Infections form an important differential diagnosis with the path of spread extending from the sinus to the skull, with an intervening orbit. Fungal lesions are important differentials to be considered, extending from paranasal sinuses to the skull base. Involvement of the bony orbit by tuberculosis has been sparingly reported. However, a combination of both these infections predominantly in the orbital soft tissue has not been reported till date. To be declared cured, both the infections require a protracted treatment. The challenge to cure multiplies exponentially when these fastidious organisms invade synergistically a host marred with systemic illness/immune deficiency. We herein report the first ever case of co-infection in the skull base and orbit by Mycobacterium tuberculosis and Aspergillus flavus.
A 65-year-old male patient, with poorly controlled diabetes mellitus, presented to us with painless, progressive diminished vision in both eyes over 4 months (asymmetrical involvement; right eye defect more than left eye). On examination, right eye had only perception of light and left eye had vision of counting fingers up to 2 feet. Fundus showed features of optic atrophy. His neurological examination was unremarkable. There were no signs of meningeal irritation. He was negative for HIV, HBsAg and HCV done by ELISA as a routine presurgical investigation. His chest X-ray was unremarkable. Mantoux was negative. Sputum AFB (done in the postoperative period after the tissue cultures showed growth of tuberculosis) was negative. Sputum for acid fast bacilli was negative. He had an FBS = 176 mg/dl, PPBS = 231mg/dl, and Hb1Ac = 8.2%. Magnetic resonance imaging (MRI) of brain with orbit showed a lesion, which was heterogeneously hypointense on T1W and hyperintense on T2W, located in the orbit, encircling the optic nerve and was extending through the optic foramen into the cranial cavity. On gadolinium contrast T1W imaging, the lesion was brilliantly enhancing and was extending onto the planum sphenoidale [
Tubercular foci maybe found in different tissues because of hematogenous spread of bacilli. Endemicity for tuberculosis may well be the explanation for the high incidence of orbital tuberculosis as compared with nonendemic countries. Orbital infections commonly manifest as osteitis, as no bone seems to be exempted from tuberculosis.[
Detection of acid fast bacilli is difficult in pathological specimens especially extra-pulmonary as they are paucibacillary.[
Invasive fungal infection involving anterior skull base and brain is an opportunistic infection commonly caused by mucor and aspergillus. It usually occurs in patients with systemic illnesses and is associated with diabetes mellitus in up to 37%.[
A combination of invasive fungal and tuberculous infection involving he orbit has never been described. This case proves the synchronism of existence of two common opportunistic infections fungal and tuberculosis in an immunocompromised patient and such an occurrence could be very aggressive and devastating like in our case.
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