Invasive orbital Aspergillosis in an immunocompetent individual after functional endoscopic sinus surgery

Abstract

Invasive orbital aspergillosis is a rare clinical entity reported in immunocompetent individuals from tropical areas like India. We are reporting a rare clinical presentation of this condition, which was precipitated by functional endoscopic sinus surgery (FESS).

Keywords: Aspergillus flavus, functional endoscopic sinus surgery, invasive orbital aspergillosis

How to cite this article:
Kumar M A, Krishnagopal S, Manivannan D, Ramraj V. Invasive orbital Aspergillosis in an immunocompetent individual after functional endoscopic sinus surgery. Ann Trop Med Public Health 2013;6:254-5

 

How to cite this URL:
Kumar M A, Krishnagopal S, Manivannan D, Ramraj V. Invasive orbital Aspergillosis in an immunocompetent individual after functional endoscopic sinus surgery. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Oct 31];6:254-5. Available from: https://www.atmph.org/text.asp?2013/6/2/254/116499

 

Introduction

Paranasal sinus infection by Aspergillus can be sinusitis; can be invasive or non-invasive. Invasive infections can be localized or fulminant. The localized form spreads from the sinuses to adjacent structures through focal bony erosion or even through vessel walls, and the fulminant form presents with multiple organ involvement. [1] Delayed detection of the localized form can be lethal to the patient because orbital infection allows for the intracranial spread. We are reporting a case of intra-orbital aspergillosis in an immunocompetent individual precipitated by functional endoscopic sinus surgery (FESS).

Case Report

A 37-year-old male had undergone FESS six months back for chronic nasal obstruction diagnosed as nasal polyp. He started developing gradually increasing nodular mass above and below the right medial canthal region one month after the procedure. Patient had visited multiple ophthalmologists before presenting to us with a hard, non-tender, nodular mass extending above and below the medial canthus [Figure 1]. The posterior extension of the mass into the orbit could not be made out. Computerized tomography (CT) scan showed a heterogenous enhancing soft tissue lesion in the anterior inferomedial aspect of right orbit with pre- and post-septal components. Extension into anterior ethmoid air cells with erosion of lacrimal bone and medial wall of orbit was present [Figure 2].

Figure 1: Clinical photograph showing a nodular mass above and below the medial canthus

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Figure 2: Computerized tomography scan showing the heterogeneous mass in the medial aspect of right orbit with extension into anterior ethmoid air cells and erosion of medial wall of orbit

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Anterior orbitotomy was performed [Figure 3], and two yellowish-gray nodules 1.5 cm x 1 cm and 1.2 cm × 0.8 cm were excised. Histopathological evaluation revealed a fungal granuloma [Figure 4]. Patient came for review after 15 days with recurrent nodule underlying the incision. Re-exploration was done, and the removed nodule was sent for fungal culture, which grew Aspergillus flavus after % days. During the re-exploration, irrigation of the deeper tissues was done with amphotericin B (5 mg/ml). Part of the wound was left open to perform amphotericin B irrigation for another five days. Patient was also started on oral itraconazole 200 mg once-daily, which is being continued for the past two months. Patient is being followed up with no recurrence of the mass.

Figure 3: Anterior orbitotomy with excision of yellowish-grey nodule

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Figure 4: Histopathology showing fungal filaments with giant cells

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Discussion

Invasive aspergillosis of orbit in immunocompetent patient is a rarely reported entity from tropical areas with a mean age of presentation of 35 and 37 years in Indian studies. [2],[3] Puskher et al. reported a major series of 15 cases of IOA along with a review of 30 years of literature. [2] Proptosis was the major clinical presentation. Paranasal sinus involvement was present in 60-90% of the patients in their series as well as in the review. But, none of those patients had developed IOA following FESS. The patient, we are reporting, developed progressive hard nodules above and below the medial canthus after sinus surgery without significant proptosis, suggesting a different clinical presentation.

The diagnosis may be delayed because biopsy from sinus may not identify the fungus with a sensitivity of 33% for sinus biopsy as reported by Diwakar et al[3] A delayed diagnosis and treatment with steroids can worsen the prognosis even causing mortality. [1] Treatment includes local debridement [4] to exenteration [3] and systemic amphotericin B, itraconazole, and voriconazole. [1] Intra-lesional amphotericin has also shown to be effective. [5] In this case, being reported local excision with amphotericin B irrigation and oral itraconazole for two months (being continued) has controlled the infection. This case is being highlighted for the variable presentation (precipitation by FESS) and the need to keep this condition in differential diagnosis of orbital mass since delay in treatment is potentially harmful.

References

 

1. Levin LA, Avery R, Shore JW, Woog JJ, Baker AS. The spectrum of orbital aspergillosis: a clinicopathological review. Surv Ophthalmol 1996;41:142-54.
2. Pushker N, Meel R, Kashyap S, Bajaj MS, Sen S. Invasive aspergillosis of orbit in immunocompetent patients: treatment and outcome. Ophthalmology 2011;118:1886-91.
3. Dhiwakar M, Thakar A, Bahadur S. Invasive sino-orbital aspergillosis: Surgical decisions and dilemmas. J Laryngol Otol 2003;117:280-5.
4. Adler SC, Isaacson G, Sasaki CT. Invasive aspergillosis of the paranasal sinuses and orbit: can you save the eye? Am J Otolaryngol 1997;18:230-4.
5. Mainville N, Jordan DR. Orbital Apergillosis Treated with Retrobulbar Amphotericin B. Orbit 2012;31:15-7.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.116499

Figures

[Figure 1], [Figure 2], [Figure 3], [Figure 4]

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