[Acute and fulminant fungal sinusitis in immunosuppressed patients]

[Inflammatory diseases of the paranasal sinuses: orbital and periorbital complications]

BACKGROUND

In most cases bacterial infections of orbital and periorbital structures constitute inflammatory processes transmitted from the paranasal sinus system. The anatomical continuity of the paranasal sinuses to the orbit and also to the brain is the main reason for the occurrence of serious or even life-threatening complications.

MATERIAL AND METHODS

Under consideration of the literature and selected clinical cases, the pathogenesis, diagnostic standards and therapy strategies are discussed with respect to the stage of the disease and the clinical course.

CONCLUSIONS

Inflammatory periorbital and orbital complications require immediate otorhinolaryngological diagnosis and therapy and therefore, interdisciplinary cooperation with ophthalmologists and radiologists is indispensable. In particular the infrequent, but still seriously life-threatening processes associated with a 5-10% fatality rate must be diagnosed and treated as early as possible. In these cases the inclusion of neurosurgery and intensive care into a complex treatment management is necessary in order to prevent severe progression with endocrinal complications or even fatal outcome.

[Invasive aspergillosis of the skull base with orbit infiltration]

BACKGROUND

[corrected] Aspergillosis of the paranasal sinuses is subdivided into noninvasive and invasive types, depending on invasion of the tissue. The invasive form often occurs in immunodeficient patients and can be divided further into granulomatous, chronic invasive, and acute fulminating forms.

CASE REPORT

We report the clinical course of an immunosuppressed 64-year-old male with invasive aspergillosis originating from the sphenoid sinus with infiltration of the orbit and intracranial extension into the cavernous sinus. The patient was referred to our hospital with loss of vision, ptosis, and ophthalmoplegia of 3-month duration. Additionally he suffered from diabetes mellitus II and kidney failure after kidney transplantation. After CT scanning, endonasal sinus debridement and decompression of the orbit were carried out immediately. Histology revealed invasive aspergillosis. Postoperatively, both systemic and local antimycotic therapy and antibiotic treatment were performed. According to recommendations of the Undersea and Hyperbaric Medicine Society, cerebral abscess is a certain indication of hyperbaric oxygenation. We decided to attempt therapy for that as well. The patient died 3 weeks after surgical intervention due to carotid dissection.

CONCLUSION

Invasive aspergillosis of the paranasal sinuses and the skull base of immunsuppressed patients is usually lethal because of intracranial complications. Therefore, fast diagnosis using CT and MRI and surgical and antimycotic therapy are necessary.

Sinusites fongiques d'origine dentaire. À propos d'une observation chez un hémodialysé chronique

About an observation of aspergillus sinusitis in an hemodialyzed patient, correlation between chronic maxillary sinusitis, its aspergillus origin and previous dental treatments is emphasized. Eventual severe complications then evolved in immunocompromised patients justify having the knowledge of this possible pathology in hemodialyzed and transplanted patients.

Safety of Caspofungin for Treating Invasive Nasal Sinus Aspergillosis in a Kidney Transplant Recipient

INTRODUCTION

Invasive fungal sinusitis is a rare but often fatal infection in immunocompromised patients. Aggressive antifungal treatment is mandatory, but is not without risk. Caspofungin, an antifungal agent that is a member of the echinocandin family, an inhibitor of glucan synthesis in the fungal wall, is active against Aspergillus and Candidae infections. Although it works on the fungal wall, it does not affect mammalian cells; hence, its toxicity is minimal.

CASE SUMMARY

This report describes a case of invasive Aspergillus sinusitis in a kidney transplant recipient with diabetes mellitus. The infection involved the apex of the right orbit causing optic nerve compression. The patient was treated with transnasal endoscopic decompression of the optic nerve and intravenous AmBisome (liposomal amphotericin B) for 2 weeks without clinical improvement. The combination of caspofungin and AmBisome administered for another 2 weeks yielded partial improvement. The AmBisome had to be discontinued due to deterioration of renal and hepatic function, but the patient completed a further 7-week course of caspofungin alone. Retro-orbital biopsy confirmed a complete response to treatment; the patient's renal and hepatic function returned to normal.

CONCLUSION

This case indicates that caspofungin is effective to treat invasive Aspergillus sinusitis in kidney transplant recipients. This agent is well tolerated and safe with respect to renal and hepatic function.