Invasive Sino-aspergillosis in Immunocompetent Individuals: Atypical Presentations

Abstract

Aims: To describe the demographic, clinical and radiological findings of invasive aspergillosis of the orbit and paranasal sinuses in immunocompetent individuals that presented without any nasal symptoms and to review the role of voriconazole in such cases. Materials and methods:A series of 13 cases is being reported with review of literature. All these cases except one underwent complete surgical debridement of the disease at the time of biopsy. On histopathological confirmation of invasive aspergillosis, the cases with sphenoid sinus involvement were given 2.5 gm of intravenous Amphotericin B (1 mg/kg/day) followed by oral itraconazole in a dose of 10 mg/kg/day for 6 months. The cases where there were lesser chances of intracranial involvement or the cases that refused for intravenous Amphotericin B were started on voriconazole 200 mg twice a day for six to twelve months. All these cases were followed up with the help of radiology, clinical improvement in symptoms and signs and fungal serology. Results:We found isolated sphenoid sinus involvement in 10 (76.92%) cases, isolated maxillary sinus involvement 2 (15.38%) cases and isolated orbital involvement 1 (7.69%). Our protocol was successful in 11 (84.61%) cases, one patient was lost to follow-up while one died due to intracranial complications during the third week of therapy.Conclusion: This study showcased the atypical presentations of invasive aspergillosis in immunocompetent individuals and the high degree of suspicion required to diagnose this entity. An aggressive, effective and optimal management protocol has been suggested and the role of voriconazole has been highlighted.

Invasive Aspergillosis in an Immunocompetent Asian Teenager

“…The pain antecedes ophthalmic signs and is consistent with a lesion arising in the sphenoid sinus, which commonly is the site of origin. This presentation suggests a long differential diagnosis, including other infectious, inflammatory, neoplastic, vascular, and neuro-ophthalmic disorders [5][6][7][8][9]. Some of these lead to corticosteroid administration, which worsens aspergillosis infection.…”

“…In Chronic invasive fungal rhinosinusitis, dense accumulation of hyphal elements, invasion of blood vessels and surrounding tissue are seen, while, in granulomatous invasive fungal rhinosinusitis, noncaseating granuloma with Langhans-type giant cells, vascular proliferation, vasculitis and perivascular fibrosis. Granulomatous invasive type usually occurs in the immunocompetent while chronic invasive fungal rhinosinusitis occur in the immunocompromised [6,9].…”