Mucormycosis, New Causative Agents, and New Susceptible Populations: Review of Cases in a Tertiary Care Hospital in Iran (2007-2021).

Background: Mucormycosis is an aggressive opportunistic fungal infection that afflicts patients with severe underlying immunosuppression, uncontrolled hyperglycemia and/or ketoacidosis, iron overload, and occasionally healthy patients who are inoculated with fungal spores through traumatic injuries. The epidemiology of mucormycosis has changed after the COVID-19 pandemic, with mucormycosis becoming the most common and the fatal coinfection. Methods: In a retrospective, cross-sectional study, 82 hospitalized patients with a definite diagnosis of mucormycosis were reported from 2007 to 2021 in a referral, tertiary care center in Tehran, Iran. Results: The number of post-COVID cases increased 4.6 times per year, with 41.5% of patients admitted during the two years of the pandemic. Mucormycosis was more common in women (57.3%), and the most common underlying diseases were diabetes (43.7%), both COVID-19 and diabetes (23.2%), cancer (11%), rheumatic diseases (7.3%), COVID-19 without other underlying diseases (6.1%), and transplantation (4.9%). Rhino-orbito-cerebral Mucormycosis (54.9%) followed by Sino-orbital infection (23.2%) was the most common presentation. There was a significant relationship between the use of immunosuppressive agents and the development of Mucormycosis (P<0.005) The average mortality was 41.5%, but this ratio decreased to 35% during the pandemic era. Conclusion: The COVID-19 pandemic caused a 4.6-fold increase in the number of mucormycosis patients, and there was a significant relationship between hyperglycemia, corticosteroid use, and mucormycosis. The death rate during the COVID-19 pandemic has decreased by 6.5%, and during the COVID period, the interval between the arrival of a patient with mucormycosis and the start of the correct treatment was significantly decreased.

A rare case of iatrogenic intracranial hypotension due to a minor CSF leakage.

Intracranial hypotension (IH) represents a rare complication, mainly following cerebrospinal fluid (CSF) leakage at the thoracic or cervicothoracic junction level. Iatrogenic IH may be expected secondary to the previous surgery or other procedures invading the patient's dura. Magnetic resonance imaging (MRI), computerized tomography (CT) scan images, CT cisternography, and magnetic resonance cerebrospinal fluid flow (MR CSF) remains the modality of choice to establish the diagnosis. The patient is in her late sixth decade, reflecting a history of progressive headaches, nausea, and vomiting. Once a diagnosis of foramen magnum meningioma was established using MRI, total microscopic resection was applied. Brain sagging and subdural fluid collection were identified on postoperative day three, suggesting intracranial hypotension due to cerebrospinal fluid leakage. Diagnosing IH following the CSF leak during the postoperative phase remains challenging. Although rare, early clinical suspicion must be considered to establish the diagnosis.

Multiple and recurrent intracranial pseudolymphoma mimicking multiple skull base meningioma, a case report.

INTRODUCTION AND IMPORTANCE: Primary central nervous system (CNS) lymphomas (PCNSLs) comprise a heterogeneous subset of intracranial disorders, predominantly of the intraparenchymal high-grade non-Hodgkin's lymphoma. Intracranial pseudolymphoma represents an exceedingly rare entity; as few as 3 reports in the English literature. We describe the first multiple large intracranial pseudolymphomata leading to increased intracranial pressure, visual loss, and recurrence during a short while. It also represents the first report of intracranial pseudolymphoma presented as a skull base tumor. CASE PRESENTATION: We describe a 67-year-old female suffering from left-sided loss of visual acuity, headache, nausea, vomiting, and improper balance. Axial brain computed tomography (CT) scan revealed an isodense anterior interhemispheric mass lesion with surrounding edema in both frontal lobes. T1 and T2 weighted magnetic resonance imaging (MRI) and T1 weighted with gadolinium injection revealed two extra-axial isointense dural-based mass lesions with homogenous enhancement compressing both frontal lobes. The morphologic findings favored B cell pseudolymphoma and meningeal B cell lymphoid hyperplasia. One year later, she developed headaches, disorientation, and progressive meaningless speech lasting 2 months. Subsequent MRI demonstrated the rapid growth of the lesion of the lesser sphenoid wing and recurrence of the lesion at the same site of surgery, thereby undergoing revision surgery in which both tumors were maximally resected using a pterional approach. CLINICAL DISCUSSION: Intracranial pseudolymphoma remains exceedingly rare, and despite its benign cellular nature, it may proliferate and recur quickly. CONCLUSION: Intracranial pseudolymphoma should always be considered a rare but potentially differential diagnosis leading to the intraventricular lesion.

Endoscopic versus Microsurgical Resection of Third Ventricle Colloid Cysts: A Single-Center Case Series of 140 Consecutive Patients.

BACKGROUND: Both endoscopic and microsurgery transcortical resection methods are used for colloid cysts of the third ventricle but they have not been compared regarding benefits and pitfalls. METHODS: Data of patients who underwent surgical resection of third ventricle colloid cyst via either endoscopic or microsurgery approach by a single surgeon from 2005 to 2020 were retrospectively collected. After administration of criteria, 140 records were retrieved (60 patients through endoscopic resection and 80 patients by a transcranial microsurgery approach). Clinical and surgical measures were compared between the 2 types of surgery after adjustment for confounders. RESULTS: Length of hospital stay, postoperative meningitis, operation time, cyst size, and baseline comorbidities were similar between two groups. Gross total resection (GTR) was achieved for all patients in the microsurgery group, whereas in the endoscopic group, resection was lower (90% vs. 100%; P = 0.005). Intraoperative hemorrhage occurred in 14 endoscopic patients (23.3%), whereas for the microscopic group, it was zero (P < 0.001). Postoperative shunt was required for 2 patients (one in the endoscopic group and the other in the microscopic group). Two patients had tumor recurrence, both of whom were in the endoscopic group. No mortality was detected in either group. Multivariate analyses were insignificant for confounding effects of clinical and demographic factors in occurrence of worse surgical outcomes (non-GTR and hemorrhage). CONCLUSIONS: In our series, the rate of intraoperative hemorrhage was higher with the endoscopic method and GTR was lower, even after adjustment for other factors. This situation could be caused by technological shortcomings and limited space for resection maneuvers and management of complications.

The Sensorineural Hearing Loss Related to a Rare Infratentorial Developmental Venous Angioma: A Case Report and Review of Literature.

BACKGROUND: Developmental venous anomaly (DVA) is a benign venous abnormality draining normal brain parenchyma. It is mostly asymptomatic; however, rare complications such as hemorrhage may lead to symptomatic conditions. Headache and seizure are the most common symptoms. Hearing loss is an extremely rare presentation of DVA. To our knowledge, only five cases of DVA, presenting with hearing loss, had been reported so far. CASE PRESENTATION: We report the case of a 27-year-old woman who presented with a sensorineural hearing loss followed by facial paresis. Magnetic resonance imaging (MRI) and computed tomography (CT) angiography revealed hematoma with adjacent converging veins showing a typical "caput medusa" sign in the left middle cerebellar peduncle, in favor of DVA. Due to the compression effect of hematoma, she underwent surgery. Hearing loss and facial paresis improved significantly during the postoperative follow-up. CONCLUSION: Although DVA is mostly benign and asymptomatic, complications such as hemorrhage rarely occur. Hearing loss is an extremely rare presentation that can be attributable to the compression effect on the cranial nerve VII to VIII complex. In the case of compression effect or progression of symptoms, surgical intervention is necessary. A good clinical outcome could be expected postoperatively.

MRI-negative Cushing's Disease: Management Strategy and Outcomes in 15 Cases Utilizing a Pure Endoscopic Endonasal Approach.

BACKGROUND: Cushing's disease (CD) is among the most common etiologies of hypercortisolism. Magnetic resonance imaging (MRI) is often utilized in the diagnosis of CD, however, up to 64% of adrenocorticotropic hormone (ACTH)-producing pituitary microadenomas are undetectable on MRI. We report 15 cases of MRI negative CD who underwent surgical resection utilizing a purely endoscopic endonasal approach. METHODS: Endoscopic endonasal transsphenoidal surgery (EETS) was performed on 134 CD cases by a single surgeon. Fifteen cases met inclusion criteria: no conclusive MRI studies and no previous surgical treatment. Data collected included signs/symptoms, pre- and post-operative hormone levels, and complications resulting from surgical or medical management. Data regarding tumor diameter, location, and tumor residue/recurrence was obtained from both pre- and post-operative MRI. Immunohistochemistry was performed to assess for tumor hormone secretion. RESULTS: Aside from a statistically significant difference (P = 0.001) in histopathological results between patients with negative and positive MRI, there were no statistically significant difference between these two groups in any other demographic or clinical data point. Inferior petrosal sinus sampling (IPSS) with desmopressin (DDAVP®) administration was performed on the 15 patients with inconclusive MRIs to identify the origin of ACTH hypersecretion via a central/peripheral (C/P) ratio. IPSS in seven, five and three patients showed right, left, and central side lateralization, respectively. With a mean follow-up of 5.5 years, among MRI-negative patients, 14 (93%) and 12 patients (80%) achieved early and long-term remission, respectively. In the MRI-positive cohort, over a mean follow-up of 4.8 years, 113 patients (94.9%) and 102 patients (85.7%) achieved initial and long-term remission, respectively. CONCLUSIONS: Surgical management of MRI-negative/inconclusive Cushing's disease is challenging scenario requiring a multidisciplinary approach. An experienced neurosurgeon, in collaboration with a dedicated endocrinologist, should identify the most likely location of the adenoma utilizing IPSS findings, followed by careful surgical exploration of the pituitary to identify the adenoma.

Comparison of microscopic and endoscopic resection of third-ventricular colloid cysts: A systematic review and meta-analysis.

BACKGROUND AND AIM: Colloid cysts are uncommon benign lesions. There is a lack of consensus regarding the preferred surgical strategy for colloid cyst resection; the technique with the optimal rates of remission, recurrence, mortality, and complications is debatable. MATERIALS AND METHODS: To determine surgical outcomes, we performed a systematic review of the published literature on Colloid cysts. Eligible studies (n = 63) with a prospective or retrospective evaluation of endoscopic or microscopic resection of third ventricle colloid cysts were included, which contained data describing extents of resection, seizures, meningitis, and tumor recurrence. A total of 3143 patients (1741 microscopically and 1402 endoscopically operated) were included in the final analysis. RESULTS: According to the results of the meta-analysis, there was a higher rate of gross total resection (GTR) (98.15% versus 91.29%, p = 0.00), need for shunting (4.75% versus 1.46%, p = 0.04), postoperative complications (20.68% versus 10.42%, P = 0.03), mean operating time (194.18 versus 113.04 min), and duration of hospitalization (7.85 versus 4.69 days) for microscopic resection compared with endoscopic resection. While endoscopic resection is associated with a higher rate of cyst recurrence (1.78% versus 0.00%, P = 0.00), there was no difference in reoperation rate (0.49% for endoscopic versus 0.09% for microscopic resection). CONCLUSION: Microsurgical resection of third ventricle colloid cysts was associated with a higher rate of GTR and a lower rate of recurrence, while there was a lower rate of postoperative complications, duration of surgery, and shorter hospitalization period in the endoscopic group.

X-Inactive-Specific Transcript: Review of Its Functions in the Carcinogenesis.

X-inactive-specific transcript (XIST) is one of the firstly discovered long non-coding RNAs with prominent roles in the process of X inactivation. Moreover, this transcript contributes in the carcinogenic process in different tissues. In addition to interacting with chromatin modifying molecules, XIST can be served as a molecular sponge for miRNAs to modulate expression of miRNA targets. Most of the studies have indicated an oncogenic role for XIST. However, in prostate cancer, a single study has indicated a tumor suppressor role for this lncRNA. Similar result has been reported for XIST in oral squamous cell carcinoma. In hepatocellular carcinoma, breast cancer, ovarian cancer, osteosarcoma, and renal cell carcinoma, different studies have reported inconsistent results. In the present manuscript, we review function of XIST in the carcinogenesis.

An update on the role of miR-379 in human disorders.

miR-379 is a miRNA transcribed from the MIR379 locus on 14q32.31. This miRNA is located in an evolutionarily conserved miRNA cluster in an imprinted region that contains DLK1 and DIO3 genes. The mouse homolog of this miRNA has been shown to be under-expressed in response to glucocorticoid receptor deficiency. Moreover, miR-379 has a tumor-suppressive role in a wide variety of tissues including the brain, breast, lung, and liver. In addition to restraining cell proliferation and migration, miR-379 can suppress the epithelial-mesenchymal transition process. Abnormal expression of this miRNA implies the pathogenesis of Duchene muscular dystrophy, spinal cord injury, diabetic nephropathy, acute myocardial infarction, and premature ovarian failure. This review aims to the summarization of the role of miR-379 in neoplastic and non-neoplastic conditions.

Emerging role of non-coding RNAs in response of cancer cells to radiotherapy.

Radiotherapy is an effective method for treatment of a large proportion of human cancers. Yet, the efficacy of this method is precluded by the induction of radioresistance in tumor cells and the radiation-associated injury of normal cells surrounding the field of radiation. These restrictions necessitate the introduction of modalities for either radiosensitization of cancer cells or protection of normal cells against adverse effects of radiation. Non-coding RNAs (ncRNAs) have essential roles in the determination of radiosensitivity. Moreover, ncRNAs can modulate radiation-induced side effects in normal cells. Several microRNAs (miRNAs) such as miR-620, miR-21 and miR-96-5p confer radioresistance, while other miRNAs including miR-340/ 429 confer radiosensitivity. The expression levels of a number of miRNAs are associated with radiation-induced complications such as lung fibrosis or oral mucositis. The expression patterns of several long non-coding RNAs (lncRNAs) such as MALAT1, LINC00630, HOTAIR, UCA1 and TINCR are associated with response to radiotherapy. Taken together, lncRNAs and miRNAs contribute both in modulation of response of cancer cells to radiotherapy and in protection of normal cells from the associated side effects. The current review provides an overview of the roles of these transcripts in these aspects.

Surgical Outcomes of Sphenoorbital En Plaque Meningioma: A 10-Year Experience in 57 Consecutive Cases.

OBJECTIVE: Sphenoorbital en plaque meningioma is located in a sensitive and complex cranial region. Therefore the therapeutic approach for this type of tumor is of great importance. We aimed to examine the clinical and radiologic outcomes of patients diagnosed with sphenoid wing en plaque meningioma undergoing surgery. METHODS: In this case series, the results of clinical and functional assessments, as well as appearance before and after surgery, were examined in 57 patients with sphenoorbital en plaque meningioma undergoing surgery with the frontotemporal approach during 2007-2017. Data were entered in the designed forms and statistically analyzed. RESULTS: Proptosis, headache, and vision impairment were detected in 47 (83%), 33 (58%), and 16 (28%) patients, respectively. Eight (14%) patients complained of diplopia, while 3 (8%) patients complained of ptosis. In all patients, proptosis improved following surgery. Complete treatment of proptosis was reported in 42 cases, and significant improvement was observed in 5 cases. Sixteen patients experienced visual impairment before surgery, 7 of whom showed improvements after surgery, while 1 showed deteriorated visual acuity after surgery. Total tumor resection was achieved in 48 (84%) patients. Tumor relapse was reported in 7 (12.5%) patients during follow-up. One patient had undergone repeated surgery, 1 patient was treated with radiotherapy alone, and 5 patients underwent combined treatment. CONCLUSIONS: Total tumor resection can be achieved with minimal complications by using microscopic dissection and sufficient bone and orbital wall resection. An important point in the treatment of these patients is the appropriate restoration of the orbital wall.

Third ventricle hydatid cyst: A rare case report and review of the literature.

A primary intraventricular hydatid cyst is a very rare phenomenon, which is mostly located in the lateral ventricle. To the best of our knowledge, only two cases of third ventricle hydatid cyst have been reported. Herein, we present a very rare case of third ventricle hydatid cyst in a four- year-old boy with nausea, vomiting, and progressive drowsiness. Neuroradiological examination revealed a large, spherical, well-defined cystic lesion within the third ventricle. The patient underwent surgery using the anterior interhemispheric transcallosal approach, and the cyst was successfully removed using the Dowling's technique. In this case report, we described the first case of transcallosal removal of a rare third ventricle hydatid cyst, which can be considered in the differential diagnosis of suprasellar arachnoid cysts. Caution must be taken in determining the best surgical approach to prevent unexpected complications.

Pineal Region Tuberculoma Caused by Mycobacterium bovis as a Complication of Bacille Calmette-Guérin Vaccine: Case Report and Review of the Literature.

BACKGROUND: Brain tuberculoma is a rare manifestation of tuberculosis especially in immunosuppressed patients. The definitive diagnosis may be difficult owing to mimicking brain tumors and the absence of the common presentation. Bacille Calmette-Guérin (BCG) vaccine is used for protection against tuberculous meningitis and miliary disease, more so in children, and also for the treatment of bladder cancer. CASE DESCRIPTION: The following case of brain tuberculoma is a boy aged 6 months who was presented to our hospital with poor feeding, nausea and vomiting, and confusion lasting 1 month. A brain magnetic resonance imaging scan showed a large mass lesion in the pineal region with generalized hydrocephaly in which polymerase chain reaction assays of the tissue was positive for Mycobacterium bovis and had a good response to antituberculosis drugs and surgery. CONCLUSIONS: We present a case of brain tuberculoma as the complication of BCG vaccine. To our knowledge, this case is the first case of brain tuberculoma after BCG vaccination. We should consider brain tuberculoma that presents with a similar presentation in any infants with a history of BCG vaccination.