Case report
An
84-year-old diabetic patient was admitted on January 19, 2021.
presenting with right peripheral nerve palsy, intolerable otalgia,
hearing loss, dysphagia, hoarseness, and bucking. Three months prior to
admission, fungal clumps were found in his right external auditory canal
and were treated with triamcinolone acetonide and econazole nitrate
cream. Subsequently, he was diagnosed with otitis media and underwent
multiple courses of antibiotic and steroid therapy.
Magnetic resonance imaging (MRI) and computed tomography (CT) revealed
temporal bone osteomyelitis (Fig. 1). The patient underwent a
mastoidectomy and experienced relief from otoalgia. Histological
examination of intratemporal tissue showed hyperplastic fibrous tissue
with partial hyalinization and calcification; no fungi were detected
following methenamine silver staining (Fig. 2). High-throughput
sequencing did not yield any reliable positive results. The
1-3-β-D-glucan (BDG) assay and Galactomannan test (GM test) results were
55.45 pg/ml and 1.85.Concurrently,the patient developed a fever with a
productive cough,Baumanii and Candida were isolated from a sputum
analysis. Antibiotic treatment, combined with voriconazole, was
administered and discontinued after 10 days.
All the symptoms improved, but the patient began experiencing pain in
the occiput and left otalgia over the following four months, eventually
developing left hearing loss. An enhanced MRI showed skull base
osteomyelitis (SBO), small abscesses in the prevertebral space, and
enhanced thickened dura (Fig. 3). The values of the BDG assay and GM
test increased to 70.7 pg/ml and 4.5, respectively. The patient was
diagnosed with basicranial Aspergillus infection and treated with
voriconazole. Blood drug concentration and GM test were monitored
monthly. The GM test value gradually declined to below 0.5 in 6 months,
with clinical and radiological remission and no change in liver and
renal function. The patient attempted to change or stop voriconazole,
but had to resume the medication due to an increased GM test value. To
date, the patient has remained in clinical remission for over 22 months
(Fig. 4).