This paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immunocompromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed. Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.

Although the production of virulence enzymes by Candida albicans has been extensively explored, little attention has been given to the virulence factors of C. dubliniensis. In the present study, an attempt was made to investigate phospholipase activity (Pz value) and secretory aspartyl proteinase production of C. dubliniensis and compare it with C. albicans. None of the 87 C. dubliniensis isolates tested, produced phosholipases whereas, in contrast all the 52 (100%) C. albicans isolates tested demonstrated varying degree of phospholipase activity (Pz value: 0.37-0.74), with 35 (67.3%) of them eliciting a higher phospholipase activity (Pz values between 0.37 and 0.50). Only 32% of the C. dubliniensis isolates exhibited moderate activity (score of 1+) of secretory aspartyl proteinase whereas a vast majority (68%) of them were non-proteolytic. On the contrary, a strong proteinase activity (score of 2+) was observed for 79% of C. albicans while the remaining 21% isolates showed moderate proteinase activity (score of 1+). As phospholipases and aspartyl proteinases of C. albicans are considered important virulence factors, the absence or lowered expression of these enzymes in C. dubliniensis may indicate the less virulent nature of this novel yeast species when compared with C. albicans.

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Allergic bronchopulmonary mycosis (ABPM) is a known complication of asthma and can result in progressive lung damage, respiratory failure and death. Asthma is a common disease in Saudi Arabia and until now the prevalence of ABPM has not been investigated. The aim of this study was to estimate the period prevalence of ABPM due to Aspergillus and Candida in patients with asthma. The setting was an outpatient pulmonary clinic at a university hospital in the central region of Saudi Arabia. Two hundred and sixty-four consecutive patients with asthma (150 or 57% females) were evaluated. All patients were screened for ABPM with skin prick test (SPT) using a panel of fungal antigens. Those with positive skin reactions had further clinical, immunological, respiratory and radiological assessment. ABPM was diagnosed by the presence of a minimum of five of the major criteria suggested by Rosenberg in 1977. Of the 264 patients, 62 (23%) had a positive SPT for at least one fungal allergen, of whom 44 (71%) were females (P=0.01). Seven patients (six females) were diagnosed with ABPM due to Aspergillus and (or) Candida species. Therefore, we estimate the period prevalence of ABPM to be 2.7% (95% confidence interval 1.3-5.4%). A. niger was the commonest fungal species isolated in our group. In conclusion, ABPM is not uncommon in Saudi Arabia and females seem to be more at risk. Because asthma is common, physicians need to have high index of suspicion for this disease and pursue the diagnosis with the appropriate tests.

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