Temporal lobe abscess in a patient with isolated sphenoiditis

Abstract

A 74-year-old immunocompetent man admitted for severe retro-orbital headache was diagnosed with isolated sphenoiditis. At the time of scheduled surgery, the patient was mildly obtunded, and a head CT revealed a temporal lobe abscess. The patient underwent a left temporal craniectomy and a bilateral endoscopic sphenoid sinusotomy, which revealed gross fungal debris. The patient made a full recovery with resolution of abscess and sinus findings. Suspicion for intracranial infection should be raised in any sinus patient with neurological changes. Early diagnosis with imaging studies is extremely important for surgical drainage before permanent neurological sequelae.

Keywords: Abcess; allergic sinusitis; fungal infection; headache; sinonasal; sphenoiditis; temporal lobe.

Figure 1.

Brain window head CT showing incidental sphenoiditis with no intracranial pathology.

Figure 2.

Preoperative maxillofacial high-resolution computed tomography showing bilateral isolated sphenoiditis with osteosclerotic changes.

Figure 3.

Head CT showing multiple brain abscesses within the left posterior parietal and temporal lobes, prominent vasogenic edema causing regional sulcal effacement.

Figure 4.

MRI with contrast; sphenoid sinusitis; rim enhancing lesions with surrounding edema and local mass effect in the left temporal lobe.

Figure 5.

Periodic acid schiff 100×. Branching pseudohyphae consistent with Candida spp., taken from a fungus ball removed from the sphenoid sinus.

Figure 6.

Follow-up MRI 4 months postoperatively. Surgical changes consistent with left temporal craniotomy and underlying left temporal encephalomalacia. Otherwise resolved sphenoiditis and fluid collections.