A fatal case of rhinocerebral aspergillosis: LANCET
A 27-year-old man presented to with a 4-month history of bilateral frontal headache, irritability, frontal lobe signs, bilateral proptosis, and nasal obstruction. He had no other signs or symptoms of a systemic illness. Rhinoscopy showed a soft tissue mass obstructing both nasal airways.

A CT scan of his head showed hyperdense lesions involving both the paranasal sinuses (figure), with expansions into the frontal interdiploë spaces, and some calcification (figure). An MRI scan of the brain showed a soft tissue mass extending along the anterior cranial fossa floor up to the sellar and parasellar regions (figure).

Endoscopic biopsy was inconclusive; however, because of raised intracranial pressure, the patient was taken to surgery for craniotomy and excision of the lesion. During the operation, an extradural grey-coloured, foul smelling, soft tissue mass was seen carpeting the cranial fossa floor over both frontal lobes and extending up into the air sinuses.

The extradural mass, which was found to be exerting pressure on the brain by compressing the frontal lobes without any macroscopic invasion of the dura, was excised completely. The intracranial pressure was reduced on completion of the operation.

Histopathological examination of the lesion showed septate fungal hyphae most consistent with Aspergillus spp.
In the immediate postoperative period, the patient was conscious and had no additional neurological deficits; he was also started on voriconazole.

However, 24 h post-operatively, the patient suddenly became unresponsive and needed mechanical ventilation. He remained unconscious and on the fourth day after the operation, he developed diffuse ischaemic changes-possible global ischaemia-throughout the brain and died.

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