Year : 2013 | Volume
: 6 | Issue : 1 | Page : 120--122
Invasive Aspergillus sinusitis in a young immunocompetent host: Call for early diagnosis and treatment
Ravinder Kaur1, Megha Maheshwari1, Dewan Richa2,
1 Department of Microbiology, Maulana Azad Medical College, New Delhi, India
2 Department of Medicine, Maulana Azad Medical College, New Delhi, India
Flat No 218, Sec 23, Pkt 1, Rohini, New Delhi
Invasive fungal infection of the sinuses is a rare disease entity most commonly encountered in the immunocompromised, debilitated host. We report a case of invasive fungal rhinosinusitis due to Aspergillus fumigatus in a young immunocompetent male who presented with only headache. The patient was initially taken up for fiber-optic endoscopic sinus surgery. A week later, he developed right-sided hemiparesis and left-sided facial weakness and therefore, he was given antifungal treatment. The patient, however, succumbed to the disease.
|How to cite this article:|
Kaur R, Maheshwari M, Richa D. Invasive Aspergillus sinusitis in a young immunocompetent host: Call for early diagnosis and treatment.Ann Trop Med Public Health 2013;6:120-122
|How to cite this URL:|
Kaur R, Maheshwari M, Richa D. Invasive Aspergillus sinusitis in a young immunocompetent host: Call for early diagnosis and treatment. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Sep 23 ];6:120-122
Available from: http://www.atmph.org/text.asp?2013/6/1/120/115180
Invasive fungal infection of the sinuses is a rare disease entity most commonly encountered in the immunocompromised, debilitated host. The disease remains difficult to treat, progresses rapidly, and proves to be fatal in many cases.
Aspergillus is a fungus with worldwide distribution and a common endogenous contaminate of the upper respiratory tract. It has become an increasingly recognized pathogen in the paranasal sinuses. The progression and prognosis of these diseases depends on the location and immunologic status of the patient. Invasive aspergillosis has been increasing over the last several years and has been associated with an increase in the number of patients with some form of immunodeficiency.  Invasive aspergillosis of the paranasal sinuses was reported in immunocompetent hosts for the first time by Milosev and others in 1966.  Since then, this condition was reported mainly from the tropical areas, including the Indian subcontinent. ,,,,
This case represents a non-immunologic compromised patient with intracranial extension of aspergillosis.
A 27-year-old male presented with left-sided hemiparesis and right-sided facial weakness for 4 days. The patient gave history of headache for the past 4 months. Headache was pulsating, occurring off and on and was not associated with any fever, vomiting, cough, and coryza. The patient did not have any facial or periorbital pain or swelling, nasal congestion or rhinorrhea. The patient was showing in a district medical center and was being treated with analgesics as and when required. The severe headache, however, continued and the patient was advised computed tomography (CT) scan and magnetic resonance imaging (MRI) of head and paranasal sinuses after 2 months of the beginning of headache.
The investigations revealed extensive sinusitis involving the sphenoid, ethmoid, and maxillary sinuses. Sinus endoscopy was done which revealed mucosal polyp on the right side and pus with fungal debris on the left side. Histopathology of the biopsy taken from the sinuses showed hyaline septate hyphae branching at acute angles suggestive of aspergillus invasion of the sinuses. The patient was taken up for fiber-optic endoscopic sinus surgery (FESS) and was given amphotericin therapy. During the post-operative period, the patient was treated for the headache but developed right-sided hemiparesis and over the next 3-4 days, he also developed left-sided facial weakness. It was at this time that the patient was referred to our hospital.
During the initial examination, the patient was conscious, oriented, and afebrile. General physical examination and specific system examination were also found to be normal. Central nervous system examination showed left hemiparesis with left UMN facial nerve palsy.
The patient was subjected to further investigations. Hematological parameters were not suggestive of inflammatory pathology (TLC 8600/mm 3 , DLC-P69, L28, M-01, E-02). Kidney function test and liver function tests were normal. Urine did not show any protein or glucose and culture did not show any growth. Blood sugar levels were within normal limits ruling out diabetes. Blood culture was sterile. Chest X-ray was normal. The patient was presumed to be immunocompetent as the patient was not reactive for HIV and had no diabetes mellitus, neutropenia, evidence of hematologic or any other malignancy in the body, or any concurrent infections. The patient was not taking any long-term steroid or other immunosuppressive agents.
Nasal endoscopy showed a pale right middle turbinate. Histopathologic study of biopsy specimen showed septate fungal hyphae branching at acute angles and invading the sinus mucosa. Culture of the specimen yielded Aspergillus fumigatus. MRI of the paranasal sinuses revealed local mucosal edema involving maxillary, ethmoid, frontal, and sphenoid sinuses with hemorrhagic polyp involving right maxillary antrum, mildly deviated nasal septum, and hypertrophied left inferior nasal turbinate. CT of the head revealed early hydrocephalous with infarct in the left occipital region. The patient was diagnosed as having intracranial fungal meningitis with possible vasculitis causing infarction. A lumber puncture was done and cerebrospinal fluid (CSF) was found to be positive for aspergillus antigen. Voriconazole was added to the treatment for faster recovery of the patient. The patient, however, deteriorated succumbed to the disease.
Craniocerebral invasive aspergillosis accounts for 5% of all intracranial infections. Craniocerebral invasive aspergillosis of sinonasal origin is a challenging and increasingly encountered clinical entity. It is most commonly seen in immunocompromised patients. In the case presented, an apparently normal host presented with fulminant fungal sinusitis. The most common presenting symptoms of sinusal involvement described by various authors are nasal obstruction, proptosis, fever, facial and periorbital pain and swelling, nasal congestion, rhinorrhea, and headache. , Our patient however, presented with severe headache only. This unusual presentation, which did not particularly point toward a sinus involvement and the fact that the patient was a young healthy immunocompetent adult because of which a fungal cause was not suspected initially, may have led to a delay in diagnosis.
Clinical outcomes of craniocerebral aspergillosis in immunosuppressed and apparently immunocompetent hosts are different owing to the difference in severity of infection and immune response. The mortality rate is high despite advancement in surgical techniques and availability of more potent antifungal therapeutic agents. The relapsing nature of invasive aspergillosis of the paranasal sinuses has been described earlier. , Nevertheless, the combination of complete surgical evacuation and Amphotericin B therapy after surgery produced a trend toward fewer relapses and longer intervals between relapses. In our case, the patient relapsed within 20 days of undergoing surgery with intracranial extension of the fungus. The cause may have been either incomplete surgical evacuation or delay in appropriate antifungal therapy. The role of complete surgical evacuation in reducing relapse was also noted earlier.  Newer triazoles, such as Voriconazole, have been used as primary antifungal agents in invasive aspergillosis in immunocompromised patients.
In conclusion, invasive sinus aspergillosis carries high morbidity and mortality, even in immunocompetent hosts. Diagnosis may be delayed because symptoms are indistinguishable from those of bacterial or viral causes; the syndrome is rare particularly in immunocompetent individuals. Unidentified, the condition may become complicated, with extension to the orbit, the cranium, and the cerebral tissue. To improve the outcome, the diagnosis must be done early, before the organism invade the central nervous system or vascular structures. Complete surgical evacuation followed by antifungal therapy for a few months should be considered to reduce relapse rates.
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