We report the rare case of a 19-year-old immunocompetent male suffering both from fungus balls of the sinuses and from chronic rhinosinusitis with massive polyposis. Endoscopic sinus surgery revealed grayish brown necrotic masses embedded in viscous eosinophilic mucus. Inoculated onto petri dishes, these masses as well as the mucus grew a dark pigmented fungus, which was identified as Bipolaris spicifera.
CASE REPORTA 19-year-old immunocompetent (human immunodeficiency virus negative, no evidence for malignancy) man was referred to our clinic because of restricted nasal breathing for 1 year and total nasal obstruction for more than 4 months. Computed tomography scan revealed massive sinusitis, with significant decalcification and destruction of the bone at skull base. Polyps and fungal masses had elevated the dura and extended far intracranially, especially in the frontal recess region and the roof of the anterior ethmoid. The dura appeared to be pushed against the brain for more than 1 cm on both sides (Fig. 1). On magnetic resonance imaging, however, there appeared to be no infiltration or penetration of the dura. Endoscopic examination showed a total obstruction of both nostrils with glassy polyps. Immunological examination of the patient's blood showed a highly elevated level of total immunoglobulin E (IgE) (4,446 kU per liter (kUL Ϫ1 ); normal value, Ͻ100 kUL Ϫ1 ). Specific IgE tests (UniCAP; Pharmacia, Uppsala, Sweden) yielded classes 3 and 4 for all fungal allergens tested ( ). Clinical chemistry showed no abnormalities in electrolytes, substrates, enzymes, and proteins, blood coagulation parameters were also in the normal range. The differential white blood cell count indicated significant eosinophilia (20% of leukocytes, 1 billion per liter); the basophil levels were also elevated slightly (1.6%).Endoscopic sinus surgery of both sides was performed by using VTI-Navigation (Visualization Technology, Inc./GE Medical Systems, Lawrence, Mass.). On the left side, the patient presented with a massive polyposis, with polyps protruding as far as the nasal vestibulum. Mucus masses were aspirated first and preserved for mycological examination. Then, in a stepwise fashion, the anteriormost polyps were removed until a huge mucocele of the concha bullosa of the middle turbinate was identified. This mucocele reached almost to the nasal vestibule and filled most of the nasal lumen. When opened there were massive polyps with glue-like mucus and fungal masses inside the concha. Then, in a stepwise fashion, preparation was taken further posteriorly and up, until in the posterior ethmoid skull base could be identified. Laterally, the polyps and fungal masses had protruded significantly (8 to 10 mm) toward the orbit; the bony border was missing partially. Only with navigational support was it possible to avoid all of the areas of hazard in this distorted anatomy. Removal of the glue-like inspissated material was extremely difficult and time-consuming. The sphenoid sinus was then identified and opened; it, too, was filled ...
