FUNGAL PETROCLIVAL OSTEOMYELITIS DUE TO ASPERGILLUS IN AN IMMUNOCOMPETENT PATIENT A Malik MD, S Thotamgari MD, S Kulkarni MD Department of Medicine, Louisiana State University, Shreveport, LA INTRODUCTION: Skull base osteomyelitis (SBO) is a rare entity with severe life-threatening consequences. Fungal SBO is uncommon and is usually seen in immunocompromised patients and is mostly caused by Aspergillus and Candida species. The overall mortality in SBO is around 9.5% and can go up to 50% in fungal SBO due to Aspergillus. CASE: A 62-year-old man with hypertension and well controlled type 2 diabetes (HgA1c 6.4%) presented with progressive worsening of left ear pain, neck pain and double vision for two months. About two months ago, he reported having pain in the left ear, a tympanostomy tube was placed and he was started on oral antibiotics at an outside hospital. However, he reported continuing to have left ear pain which progressed to left neck pain along with double vision. Physical examination revealed erythematous tympanic membrane and minimal purulent drainage in left ear. Left lateral gaze palsy was present on neurologic examination. Nasal endoscopy showed normal nasal mucosa. Computed Tomography scan of the temporal bone showed left petroclival hypodensity and cortical erosion. Magnetic Resonance Imaging further confirmed findings suggestive of petroclival osteomyelitis. The patient underwent left sided mastoidectomy and intraoperative cultures from left ear grew Aspergillus species. At the time of case submission, the patient was currently admitted in the hospital; being treated with intravenous voriconazole and the plan was to continue long-term intravenous antifungal treatment. Conclusion: SBO is a rare but life-threatening infection which usually starts from infection of either external ear canal or paranasal sinuses. PetroClival osteomyelitis due to Aspergillus species is a serious condition with high mortality rate and treatment includes aggressive surgical debridement, long-term culture-directed systemic antimicrobial therapy. Although the infection is very rare in immunocompetent patients, it can have significant morbidity and mortality rates up to 50%. Early diagnostic sampling along with high suspicion towards fungal infection should be considered in diabetic patients who do not improve with empirical antibiotics.
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