57-year-old male with past medical history of Type 2 diabetes mellitus, hypertension, initially presented with seizures. Neuroimaging (computed tomography and magnetic resonance imaging head) revealed a destructive mass in the right nasal cavity, destruction of the cribriform plate and mass (6 x 2 x 3 cm) in the right inferior frontal lobe. Sinus biopsy showed fungal mass which was extensively debrided and resected. In order to prevent cerebral herniation, the airway was secured with a tracheostomy, nutrition provided with gastrostomy tube. Based on culture-sensitivity, intravenous azole antifungals were begun (Isovuconazole).
He was admitted to acute inpatient rehabilitation for deconditioning caused by the traumatic brain injury (TBI) caused by fungal infection and mass resection. Despite refusal to perform therapy consistently, he progressed to performing activities of daily living (ADLs) and transfers with modified independence, speech and dysphagia improved; the tracheostomy tube removed. The patient’s diet was modified to mechanical soft with honey thick liquids. Infectious disease team advised to continue the azole antifungal orally for total 6-month duration.
The incidence of central nervous system (CNS) fungal infection is increasing, recently, in neurosurgical patients. Characterized with high mortality and morbidity rate, early aggressive surgical intervention is required. CNS fungal infections with aggressive neurosurgery and antifungal use resulted in 70% survival rate. However, since there’s no discussion or guidelines for rehabilitation course in the literature, identifying and characterizing issues could reduce morbidity.
Post-surgical CNS infection can be managed using current TBI protocol and antifungal therapy to achieve the rehabilitation goals. However, further meta-analysis or randomized controlled trials might help to characterize the rehabilitation of CNS fungal infection post-resection and optimize guidelines.