Q J Med 2003; 96: 379
© 2003 Association of Physicians
Correspondence |
Sino-cerebral aspergillosis due to chronic herbal medicine use
121st General Hospital, Seoul, Korea, e-mail: gychang{at}medimail.co.kr
Sir,
We enjoyed reading the article by Edwards et al.1 They presented a case of Cushing's syndrome from prolonged use of Chinese herbal remedy for treatment of gout. Analysis of the remedy revealed the steroidal compounds bethamethasone and dexamethasone. Subsequent correspondence highlighted another similar case after chronic use for treatment of arthritis.2 We recently encountered a case of sino-cerebral aspergillosis, a usually lethal disease, in a herbal medicine user.
A 60-year-old Korean woman had been using daily herbal remedy for her arthritis for 2 years. She was otherwise healthy and taking no other medication. She presented with 2 weeks of nasal stuffiness and 3 days of worsening headache, diplopia and decreased vision. She was febrile with a stiff neck. She was alert, and able to lift either arms on command but unable to open her eyelids. She was blind on the right eye without light perception. Both pupils were enlarged and unreactive to light. No ocular movements could be elicited. MRI scan showed pansinusitis and bilateral cavernous sinus enhancement. Spinal fluid examination showed total leukocyte count 1200/mm3 with polymorphonuclear predominance, a protein level of 151 mg/dl, and a glucose level of 29 mg/dl. Sinus mucosal biopsy showed invasive aspergillosis. She was started on intensive antifungal treatment with gradual improvement.
Cerebral aspergillosis is unusual without concomitant use of steroid even in immunocompromised hosts. Beal et al.3 collected 12 consecutive cases: six had prior renal transplant and the rest had other serious illnesses. Even in this selected group, all but one (ectopic ACTH syndrome) was on a high steroid dose at the time of diagnosis.
Our case illustrates an unusual and serious neurological illness that may result from herbal remedy use. Besides direct complications related to use of the substances itself, secondary immunosuppresion may also result in a potentially life-threatening illness.
References
1. Edwards CJ, Lian TY, Chng HH. Cushing's syndrome caused by treatment of gout with traditional Chinese medicine. Q J Med 2002; 95:705.
2. McConkey B. Adrenal corticosteroids in Chinese herbal remedies. Q J Med 2003; 96:81–2.
3. Beal MF, O'Carroll CP, Kleinman GM, Grossman RI. Aspergillosis of the nervous system. Neurology 1982; 32:473–9.
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