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).