Page 103 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Fungal markers in intracranial fungal infections

sinuses (PNSs), orbit, and cranial areas – are the primary to early diagnostic tools in resource-limited low- and
disease sites. Disease progression in these regions is middle-income countries such as Pakistan.
5
accompanied by pain, fever, ophthalmic complications,
epistaxis, and cough. The symptoms progress gradually and 2. Case series
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often include proptosis, monocular blindness, congestion, We retrospectively reviewed the medical records of
classic meningitis symptoms, and hemorrhage. Owing patients with clinically suspected IFI. Only patients with
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to its angioinvasive properties, Aspergillus can affect fungal assay data (GM and BDG levels), neuroimaging
the branches of the internal carotid artery (ICA) in the studies (computed tomography [CT] of the PNS and
ethmoidal or orbital regions, leading to microaneurysms magnetic resonance imaging [MRI]), and CSF analysis
and cerebral emboli. Furthermore, bone destruction is results were included in this study. We solely focused on
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observed in 30 – 50% of patients with sinus infections. 9 the diagnostic approach for suspected cases of IFI from a
The European Organization for Research and Treatment single center and did not address the treatment regimens
of Cancer and the Mycoses Study Group have included or management outcomes. The interpretation of the BDG
galactomannan (GM) and 1,3-β-d-glucan (BDG) assays as and GM index values is provided in Table 1.
microbiological criteria for diagnosing fungal infections. 2.1. Case 1
10
GM, a polysaccharide antigen primarily found in the cell
walls of Aspergillus spp., can be detected using the Platelia A 48-year-old man presented with headaches, vertigo,
Aspergillus enzyme immunoassay (Bio-Rad Laboratories, left-sided visual loss, and hearing loss 2 months after
Inc., headquartered in Hercules, California, USA). This surgical excision of a parasellar space-occupying lesion.
method utilizes serum or bronchoalveolar lavage fluid CSF analysis revealed an elevated protein level, a decreased
samples. However, cerebrospinal fluid (CSF) can be used glucose level, and an increased white blood cell (WBC)
to treat cerebral aspergillosis. 10-12 count (lymphocytes, 95%). The serum was positive for
BDG, whereas Gram and acid–fast bacteria staining
BDG, a cell wall component of most fungi (excluding yielded negative results.
Cryptococci, Zygomycetes, and Blastomyces dermatitidis),
is a panfungal serological marker. Although BDG is Contrast-enhanced MRI of the brain revealed an
not specific to IA, it can be used to diagnose invasive intracranial extra-axial mass in the right parasellar region.
candidiasis. 10-12 Of the four available BDG detection assays The mass extended into both cavernous sinuses and
(Fungitell, Wako, Fungitec-G, and Maruha), only Fungitell involved the right supraclinoid ICA, cerebellar peduncle,
(Associates of Cape Cod, Inc., 124 Bernard E. Saint Jean and brainstem.
Drive, East Falmouth, Massachusetts 02536-4445, USA) 2.2. Case 2
has been FDA-approved for use with serum. 10
A 51-year-old man with fungal sinusitis presented with
Pakistan faces unique challenges because of its humid
climate, which fosters fungal growth and widespread swelling in the left maxillary region 8 months after a
craniotomy. GM and BDG fungal biomarker assays were
immunosuppressive therapy use. Furthermore, owing to positive. Contrast-enhanced MRI of the brain revealed
limited data on intracranial fungal infections (IFIs) and changes in the left maxillary sinus with ipsilateral intraorbital
restricted availability and affordability of neuroimaging and intracranial extensions. The CT PNS confirmed the
or CSF analysis, diagnoses are delayed or missed. findings of chronic left maxillary sinusitis with osteomyelitis.
Consequently, the timely detection of fungal infections
must be improved by assessing specific diagnostic 2.3. Case 3
parameters such as GM and BDG assays, which can
enhance the diagnostic accuracy and facilitate prompt A 61-year-old man with hepatitis C and uncontrolled type-2
treatment. Given the low socioeconomic status of patients diabetes presented with proptosis, pain, lacrimation, and
in our setup, we must focus on targeted diagnostic Table 1. Cutoffs for the serum fungal diagnostic assays and
markers to streamline patient and healthcare provider their interpretation
processes.
Tests Cutoff Interpretation
This study contributes to the existing literature on β-d-glucan <60 pg/mL Negative
IFIs by presenting a case series of patients with IFIs who
were admitted to the Jinnah Postgraduate Medical Center, 60–80 pg/dL Intermediate*
a tertiary care hospital in Karachi, Pakistan, between >80 pg/dL Positive
November 2022 and May 2023. We aimed to evaluate the Galactomannan <0.5 Negative
potential role of serum fungal biomarkers as an adjunct Notes: *Repeat test-recommended; **GMI >0.5 in two consecutive samples.

Volume 8 Issue 2 (2025) 97 doi: 10.36922/itps.4528