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Zhang KX, Gu D, Puchi C, Welch KC, Lissner GS. Combination endoscopic surgical debridement and transcutaneous retrobulbar amphotericin B for acute rhino-orbital-cerebral aspergillosis. Am J Ophthalmol Case Rep 2023; 32:101903. [PMID: 37554299 PMCID: PMC10405185 DOI: 10.1016/j.ajoc.2023.101903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE To report a case of acute rhino-orbital-cerebral aspergillosis with aggressive intracranial and orbital extension co-managed medically and surgically with endoscopic sinus debridement and multiple retrobulbar injections of amphotericin B. OBSERVATIONS A 70-year-old male patient presented via external transfer with headaches and left ophthalmoplegia concerning for severe complicated sinusitis with intracranial and left orbital spread. His history is notable for a simultaneous heart-kidney transplant three years prior on chronic immunosuppression. Ophthalmologic examination revealed complete ophthalmoplegia in the left eye with no light perception concerning for a left orbital apex syndrome. The patient was taken to the operating room twice for endoscopic sinus debridement and three separate retrobulbar injections of amphotericin B. Fungal cultures from surgical specimens grew isolated Aspergillus fumigatus. Patient's symptoms gradually improved and repeat MRI demonstrated resolution of pansinusitis, sparing left eye exenteration. CONCLUSIONS AND IMPORTANCE Multidisciplinary management of invasive fungal rhinosinusitis in the setting of profound immunosuppression poses a significant challenge. While surgical debridement remains the cornerstone approach, the achievable reduction in disease burden may be augmented by targeted retrobulbar antimicrobials.
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Affiliation(s)
- Kevin X. Zhang
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - David Gu
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Christopher Puchi
- Department of Otolaryngology – Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Kevin C. Welch
- Department of Otolaryngology – Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Gary S. Lissner
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
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Redzuwan NS, Barr Kumarakulasinghe AL, W Md Kasim WM, Mohd Khialdin S. COVID-19-Related Rhino-Orbital-Cerebral Mucormycosis With Angioinvasion: A Lethal Sequelae. Cureus 2023; 15:e40483. [PMID: 37461781 PMCID: PMC10349690 DOI: 10.7759/cureus.40483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
A middle-aged man with multiple comorbidities including uncontrolled diabetes mellitus presented with shortness of breath and lethargy for six days. He was treated for COVID-19 pneumonia, requiring high cumulative steroid therapy. After 15 days of treatment, he developed right orbital apex syndrome with central retinal artery occlusion secondary to invasive mucormycosis. The infection progressed rapidly despite aggressive medical treatment, systemic anti-fungal therapy along with local transcutaneous retrobulbar amphotericin B injection. We report our battle in fighting this vicious disease. Judicious use of immunomodulators in COVID-19 treatment and close monitoring is crucial, especially in high-risk patients.
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Affiliation(s)
- Nur Syazwani Redzuwan
- Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
- Ophthalmology, Hospital Tengku Ampuan Rahimah, Klang, MYS
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Ashraf DC, Idowu OO, Hirabayashi KE, Kalin-Hajdu E, Grob SR, Winn BJ, Vagefi MR, Kersten RC. Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis. Am J Ophthalmol 2022; 237:299-309. [PMID: 34116011 DOI: 10.1016/j.ajo.2021.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis can reduce the risk of exenteration without compromising survival. DESIGN Retrospective, comparative clinical study with historical control subjects. METHODS Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasiexperimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes. RESULTS Baseline characteristics did not differ significantly between the 2 groups. Nearly all patients underwent a surgical intervention, most commonly functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs 9.1% [95% confidence interval {CI} 5.2-48.8]; P = .014), while mortality was similar (40.0% vs 36.7% [95% CI -22.1 to 29.3]; P = .816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (relative risk 0.28 [95% CI 0.08-0.99]; P = .049) and similar risk of mortality (relative risk 1.04 [95% CI 0.50-2.16]; P = .919). CONCLUSION Compared with historical control subjects, patients with invasive fungal rhino-orbital sinusitis who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.
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Affiliation(s)
- Davin C Ashraf
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Oluwatobi O Idowu
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Kristin E Hirabayashi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Evan Kalin-Hajdu
- Department of Ophthalmology (E.K-H.), Université de Montréal, Montreal, Quebec, Canada
| | - Seanna R Grob
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Bryan J Winn
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - M Reza Vagefi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Robert C Kersten
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA.
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Chiou CA, Yoon MK. An Update on Fungal Orbital Infections. Int Ophthalmol Clin 2022; 62:55-69. [PMID: 35325910 DOI: 10.1097/iio.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Murthy R, Bagchi A, Gote Y, Desai S. Retrobulbar injection of amphotericin B using intravenous cannula for post-COVID-19 rhino-orbital mucormycosis. Indian J Ophthalmol 2021; 70:302-305. [PMID: 34937263 PMCID: PMC8917598 DOI: 10.4103/ijo.ijo_1511_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rhino-orbital mucormycosis has seen a huge resurgence in patients post COVID-19 infection. In patients with minimal orbital disease and especially with preserved vision, retrobulbar injections of amphotericin B can be of great help in controlling the disease. Instead of giving daily injections of amphotericin B using needles every time, we used an 18-gauge intravenous (IV) cannula with injection port and suture holes to deliver the amphotericin into the orbital space for a period of 5 days. Patients were more compliant and less distressed with this method compared with being given an injection with a needle daily. We got a good response in terms of orbital disease regression with this method. In our review of the literature, we did not come across any such case of amphotericin B injection using an IV cannula. Injection of amphotericin B into the orbit using an IV cannula is a viable and easy treatment option for cases of rhino-orbital mucormycosis.
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Affiliation(s)
- Ramesh Murthy
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Aadhyaa Bagchi
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Yogita Gote
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Sanjay Desai
- Department of Radiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
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Mekonnen ZK, Ashraf DC, Jankowski T, Grob SR, Vagefi MR, Kersten RC, Simko JP, Winn BJ. Acute Invasive Rhino-Orbital Mucormycosis in a Patient With COVID-19-Associated Acute Respiratory Distress Syndrome. Ophthalmic Plast Reconstr Surg 2021; 37:e40-e80. [PMID: 33229953 PMCID: PMC7927902 DOI: 10.1097/iop.0000000000001889] [Citation(s) in RCA: 148] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
Acute invasive fungal rhinosinusitis is a rare, although highly morbid, infection primarily affecting immunosuppressed individuals. The same population is at particularly high risk of complications and mortality in the setting of SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. The authors present a case of acute invasive fungal rhino-orbital mucormycosis in a patient with COVID-19 and discuss the prevalence, diagnosis, and treatment of fungal coinfections in COVID-19. Prompt recognition, initiation of therapy, and consideration of the challenges of rapidly evolving COVID-19 therapy guidelines are important for improving patient survival.
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Affiliation(s)
| | | | - Tyler Jankowski
- Department of Pathology, University of California, San Francisco
| | | | | | | | - Jeffry P. Simko
- Department of Pathology, University of California, San Francisco
| | - Bryan J. Winn
- Department of Ophthalmology
- Ophthalmology Section, Surgical Service, San Francisco Veterans Affairs Medical Center, San Francisco, California, U.S.A
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Chen AJ, Ediriwickrema LS, Verma R, Vavinskaya V, Shaftel S, Deconde AS, Korn BS, Kikkawa DO, Liu CY. A case of mistaken identity: Saksenaea vasiformis of the orbit. Orbit 2020; 40:521-524. [PMID: 32862746 DOI: 10.1080/01676830.2020.1814354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The authors describe a rare presentation of invasive fungal rhino-orbital cellulitis caused by Saksenaea vasiformis in an immunocompetent child. The patient was initially diagnosed and treated as Mucoraceae, which has a high mortality rate and is primarily seen in immunocompromised patients. Though of the same order, Mucorales, the families Mucoraceae and Saksenaeacae, may be difficult to differentiate on histologic examination and must be distinguished by fungal culture and speciation. Our patient responded well to sino-orbital debridement and systemic treatment with amphotericin and posaconazole.
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Affiliation(s)
- Allison J Chen
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
| | - Lilangi S Ediriwickrema
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
| | - Rohan Verma
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
| | | | - Solomon Shaftel
- Department of Ophthalmology, Kaiser Permanente, San Diego, California, USA
| | - Adam S Deconde
- Division of Otolaryngology, Head and Neck Surgery, UC San Diego, La Jolla, CA, USA
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA.,Division of Plastic Surgery, UC San Diego, La Jolla, CA, USA
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA.,Division of Plastic Surgery, UC San Diego, La Jolla, CA, USA
| | - Catherine Y Liu
- Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
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Safi M, Ang MJ, Patel P, Silkiss RZ. Rhino-orbital-cerebral mucormycosis (ROCM) and associated cerebritis treated with adjuvant retrobulbar amphotericin B. Am J Ophthalmol Case Rep 2020; 19:100771. [PMID: 32551404 PMCID: PMC7287239 DOI: 10.1016/j.ajoc.2020.100771] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose We report a case of rhino-orbital-cerebral mucormycosis (ROCM) with focal anterior cerebritis treated favorably with retrobulbar amphotericin B and systemic antifungals. Observations A 55-year-old diabetic male presented to the emergency department with left sided proptosis, left temple headache, maxillary sinus pain, and diplopia of 3 days duration. Biopsy results from the left middle turbinate, ethmoid, and maxillary sinus revealed broad and irregular non-septate hyphae consistent with mucormycosis. Despite treatment with intravenous antifungals and endoscopic debridement of the sinuses, his condition did not improve. Disease progression included the development of left ophthalmoplegia and left-sided cerebritis. The patient received retrobulbar injection of deoxycholate amphotericin B with eventual disease resolution, without exenteration. Conclusions We present a case of ROCM with associated cerebritis that responded to retrobulbar amphotericin B, without exenteration.
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Affiliation(s)
- Mustafa Safi
- California Pacific Medical Center, San Francisco, CA, United States
| | - Michael J Ang
- California Pacific Medical Center, San Francisco, CA, United States
| | - Poorav Patel
- California Pacific Medical Center, San Francisco, CA, United States
| | - Rona Z Silkiss
- California Pacific Medical Center, San Francisco, CA, United States.,Silkiss Eye Surgery, San Francisco, CA, United States
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Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality. Ophthalmic Plast Reconstr Surg 2019; 35:535-542. [DOI: 10.1097/iop.0000000000001357] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
PURPOSE OF REVIEW To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit. RECENT FINDINGS Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options. SUMMARY Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.
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Abstract
A 68-year-old immunocompromised man with rhino-orbital-cerebral mucormycosis was treated with retrobulbar injections of amphotericin B deoxycholate in conjunction with intravenous antifungals and endoscopic sinus debridement. Transient episodes of orbital inflammation were noted after retrobulbar injections, but progression of orbital infection was halted and visual acuity restored with eventual hospital discharge. To the authors' knowledge, clearance of orbital mucormycosis with retrobulbar amphotericin B injections has not been previously reported. This intervention may be a viable therapeutic option in cases of orbital mucormycosis where aggressive orbital debridement is not favored and/or the burden of orbital disease is not substantial. However, physicians should be aware of the risk of transient orbital inflammation secondary to retrobulbar amphotericin B deoxycholate.
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Kim SY, Ko SJ, Choi KH, Kim SD. Treatment of Rhino-Orbito-Cerebral Aspergillosis with Combination of Amphotericin, Posaconazole and Amphotericin Irrigation: A Case Report. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.6.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sang Yeop Kim
- Department of Ophthalmology, Wonkwang University School of Medicine, Iksan, Korea
- Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sang Jun Ko
- Department of Ophthalmology, Wonkwang University School of Medicine, Iksan, Korea
- Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Keum Ha Choi
- Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
- Department of Pathology, Wonkwang University School of Medicine, Iksan, Korea
| | - Sang Duck Kim
- Department of Ophthalmology, Wonkwang University School of Medicine, Iksan, Korea
- Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
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Soki H, Abo K, Yamazaki K, Kojima T, Oda T, Uzawa Y, Kikuchi K. [First Report of Intraorbital Abscess Caused by Candida allociferrii and Specific PCR for Differentiating Stephanoascus ciferrii Complex Species]. Med Mycol J 2016; 56:E9-14. [PMID: 26073792 DOI: 10.3314/mmj.56.e9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a rare case of intraorbital abscess caused by Candida allociferrii, which was described as a new species of Stephanoascus ciferrii complex in 2002, in a patient after enucleation of choroidal melanoma. This strain showed resistance to itraconazole, and fluconazole. After debridement and topical use of amphotericin B, his wound abscess was disappeared. To our knowledge, this is the first C. allociferrii infection case in human.
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Affiliation(s)
- Hironobu Soki
- Department of Clinical Laboratory, Saitama Red Cross Hospital
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The Role of Adjunctive Therapies in the Management of Invasive Sino-Orbital Infection. Ophthalmic Plast Reconstr Surg 2016. [PMID: 26207927 DOI: 10.1097/iop.0000000000000488] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection. METHOD & RESULTS Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described. CONCLUSION Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.
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Brodie FL, Kalin-Hajdu E, Kuo DS, Hirabayashi KE, Vagefi R, Kersten RC. Orbital compartment syndrome following retrobulbar injection of amphotericin B for invasive fungal disease. Am J Ophthalmol Case Rep 2016; 1:8-10. [PMID: 29503880 PMCID: PMC5757339 DOI: 10.1016/j.ajoc.2016.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/12/2016] [Accepted: 01/14/2016] [Indexed: 12/01/2022] Open
Abstract
Purpose To describe a complication of retrobulbar amphotericin B injections in the treatment of invasive rhino-orbital asperigillosis. Observations 27 year-old renal transplant recipient presented with a two-week history of headache, binocular diplopia and proptosis of the left eye. Endonasal biopsy on hospital day 3 confirmed the diagnosis of rhino-orbital invasive Aspergillus fumigatus involving the left orbital apex. In addition to systemic antifungal treatment and cessation of immunosuppression, retrobulbar amphotericin B injections (3.5 mg/1 ml) combined with endoscopic local debridement were initiated when the patient developed progressive visual loss. Retrobulbar injections were administered on hospital days 8, 10, 14, 17, and 20. Endoscopic debridement occurred on hospital days 10 and 16. After the fifth retrobulbar amphotericin B injection, the patient developed acute orbital compartment syndrome with intraocular pressures ranging from 47 to 86 mmHg and vision declined to 20/200, requiring emergent lateral canthotomy and superior and inferior cantholysis. Close observation without further intervention resulted in return of vision to 20/20 and normalization of intraocular pressure. Conclusion and importance Retrobulbar amphotericin B in combination with local debridement may be considered an alternative to exenteration for invasive aspergillosis secondary to reversible immunosuppression. To the authors' knowledge, orbital compartment syndrome secondary to retrobulbar amphotericin B administration has not previously been reported. Patients should be counseled on the risk of severe local inflammation due to amphotericin B. More research is needed to establish the most appropriate dosing, frequency, and duration of retrobulbar amphotericin B injections in the treatment of life-threatening Aspergillus infections.
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Affiliation(s)
- Frank L Brodie
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Evan Kalin-Hajdu
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Debbie S Kuo
- Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Kristin E Hirabayashi
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Reza Vagefi
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Robert C Kersten
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
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Invasive fungal sinusitis of the sphenoid sinus. Clin Exp Otorhinolaryngol 2014; 7:181-7. [PMID: 25177433 PMCID: PMC4135153 DOI: 10.3342/ceo.2014.7.3.181] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/13/2022] Open
Abstract
Objective This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival. Methods A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted. Results Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P=0.027). Conclusion The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus.
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Abstract
A 61-year-old male underwent a cardiac transplant for congenital dilated cardiomyopathy. Two months post-transplantation, after a complicated clinical course, he was noted to have progressive proptosis and limitation of motility OD. Computed tomography showed opacification of the right maxillary sinus with the suggestion of a fungus ball and soft tissue infiltration along the floor of the orbit adjacent to the inferior rectus, extending posteriorly to within millimeters of the superior and inferior orbital fissures. An orbital biopsy demonstrated the presence of fungal hyphae and A. fumigatus was cultured. The patient was treated with systemic antifungal therapy and intralesional retrobulbar amphotericin B (without debridement) with successful eradication of the fungal pathogen. Intralesional amphotericin in combination with systemic antifungal therapy without limited debridement is rarely reported and may be an alternative to limited debridement or exenteration in orbital aspergillosis.
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Affiliation(s)
- Norman Mainville
- Department of Ophthalmology, University of Ottawa Eye Institute and The Ottawa Hospital, 301 O'Connor St., Ottawa, Ontario, Canada
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Giordano C, Gianella P, Bo S, Vercelli A, Giudice C, Santa DD, Maria A, Peruccio C, Peano A. Invasive mould infections of the naso-orbital region of cats: a case involving Aspergillus fumigatus and an aetiological review. J Feline Med Surg 2010; 12:714-23. [PMID: 20800212 PMCID: PMC11148993 DOI: 10.1016/j.jfms.2010.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2010] [Indexed: 12/31/2022]
Abstract
CASE AND CONTEXT: This report describes a cat diagnosed with sinonasal-orbital Aspergillus fumigatus infection using advanced imaging, histopathology and culture. Aetiology, clinical aspects and treatment of this rare and devastating infection are discussed with reference to a literature review of invasive mould (ie, filamentous fungal) infections involving tissues of the naso-orbital region of cats. PRESENTATIONS Invasive fungal infections can present with different localisations (nasal passages, sinuses, orbits, subcutaneous space, palate, etc) depending on the species involved and its means of introduction into the tissues. Localised subcutaneous lesions (swellings, ulcerations, masses, nodules, etc), without concomitant signs of nasal/orbital disease, generally result from traumatic injuries and subsequent inoculation of fungal spores into the subcutaneous space. In contrast, naso-ocular involvement and concurrent signs of nasal disease (nasal discharge, sneezing, masses protruding from the nostrils) generally result from inhalation of spores, with subsequent spread of infection into the nasal planum or penetration of overlying bone and invasion of the subcutaneous space. Aspergillus species typically show such an invasion mechanism and frequently affect orbital tissues. Dematiaceous fungi (ie, filamentous fungi with brown/black hyphae) are reported to cause solitary, less invasive, slowly developing lesions, probably as a result of traumatic injuries with inoculation of fungal propagules. Accordingly, the subcutaneous space is more frequently primarily involved. TREATMENT AND OUTCOME Whatever the mould species, reported treatment options include surgery and a series of antifungal drugs. The outcome is frequently poor, especially for Aspergillus infections, although various measures can be taken to maximise the chances of success, as discussed in this report.
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Affiliation(s)
| | - Paola Gianella
- Dip. di Patologia Animale, Facoltà di Medicina Veterinaria, Université degli Studi di Torino, Italy
| | | | | | - Chiara Giudice
- Dip. di Patologia Animale, Igiene e Sanità Pubblica Veterinaria, Facoltà di Medicina Veterinaria, Université degli Studi di Milano, Italy
| | | | - Anna Maria
- Dip. di Sanità Pubblica, Microbiologia, Virologia, Université degli Studi di Milano, Italy
| | | | - Andrea Peano
- Dip. di Produzioni Animali, Epidemiologia ed Ecologia, Facoltà di Medicina Veterinaria, Université degli Studi di Torino, Italy
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