What is the diagnosis and treatment for Aspergillosis (fungal infection) with osteomyelitis (bone infection) at the base of the skull?

From the Guidelines

Diagnosis and treatment of Aspergillosis with osteomyelitis at the base of the skull is a complex process that requires aggressive diagnostic and therapeutic intervention.

Diagnosis

The diagnosis of Aspergillosis with osteomyelitis at the base of the skull involves a combination of clinical, radiological, and microbiological findings.

• Key diagnostic tools include:
  • CT and/or MRI scans to stage the disease and guide surgical intervention 1
  • Identification of the causative etiology to species level and saving the isolate for future antifungal susceptibility testing 1

Treatment

The primary treatment for Aspergillosis with osteomyelitis at the base of the skull is voriconazole, which is recommended as the primary systemic antifungal therapy (A-II) 1.

• Alternative treatments include:
  • Itraconazole, posaconazole, or liposomal amphotericin B (LFAB) for patients who are intolerant or refractory to voriconazole (B-III) 1
  • Combination therapy with voriconazole and caspofungin, although there is limited data to support this approach 1
• Surgical intervention is also recommended, where feasible, to prevent serious neurological sequelae and improve outcome 1
• Reversal of underlying immune deficits is paramount for successful outcome of CNS aspergillosis 1
• Corticosteroids should be avoided where possible, as they can be deleterious in this context (C-III) 1

Additional Considerations

• Duration of therapy has not been optimally defined, but most experts attempt to treat pulmonary infection until resolution or stabilization of all clinical and radiographic manifestations 1
• Prophylaxis against invasive aspergillosis may be necessary for patients who require subsequent immunosuppression after successful treatment of IA 1

From the Research

Diagnosis of Aspergillosis with Osteomyelitis at the Base of the Skull

• The diagnosis of Aspergillosis with osteomyelitis at the base of the skull can be challenging due to its rarity and non-specific symptoms 2, 3.
• A combination of clinical examination, laboratory findings, imaging studies (CT and MRI), and serum galactomannan assay can aid in diagnosis 2, 4.
• Fungal culture and histopathology are essential for definitive diagnosis 4.
• The presence of lower cranial nerve palsies and lack of response to culture-directed antibiotics may indicate a fungal etiology 2.

Treatment of Aspergillosis with Osteomyelitis at the Base of the Skull

• The treatment of Aspergillosis with osteomyelitis at the base of the skull typically involves antifungal therapy, with or without surgical intervention 5, 4.
• Voriconazole is a commonly used antifungal agent for the treatment of Aspergillus osteomyelitis 4.
• Surgical debridement may be necessary in some cases to remove infected tissue and promote healing 5, 4.
• The duration of antifungal therapy can vary, but prolonged treatment (median 90 days) is often necessary to achieve a complete response 5.
• Early diagnosis and treatment are crucial to improve outcomes and reduce mortality 3, 6.

Clinical Presentation and Epidemiology

• Aspergillosis with osteomyelitis at the base of the skull can affect both immunocompromised and immunocompetent patients 5.
• The most common sites of infection are the vertebrae, cranium, and ribs 5.
• Patients with underlying medical conditions, such as diabetes mellitus, chronic otitis externa, and immunosuppression, are at increased risk of developing fungal osteomyelitis 2, 3.
• The clinical presentation can vary, but common symptoms include pain, tenderness, and cranial nerve deficits 2, 5.