Invasive Aspergillusterreus sinusitis with orbitocranial extension: case report

Background: Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient.

Case description: This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month.

Conclusion: A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.