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Simmons BA, Kupcha AC, Law JJ, Wang K, Carter KD, Mawn LA, Shriver EM. Misdiagnosis of fungal infections of the orbit. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:449-454. [PMID: 35525264 DOI: 10.1016/j.jcjo.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/12/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the accuracy of the initial diagnosis in the case of fungal infections of the orbit and identify factors that may influence patient outcomes. METHODS An institutional review board-approved retrospective chart review was conducted across 2 large academic centres to identify cases of fungal infections involving the orbit from January 1, 1998, to November 15, 2019. Data collected included patient demographics, past medical history, examination findings, diagnosis, treatment, imaging, and outcomes. RESULTS Fifty cases of fungal infection involving the orbit were identified. Of these, 33 (66.0%) were initially misdiagnosed as nonfungal diagnoses. Sixteen patients (32.0%) received multiple initial diagnoses. The most common diagnoses on presentation were bacterial cellulitis (n = 12 of 50; 24.0%) and bacterial sinusitis (n = 12 of 50; 24.0%). These were followed by vascular and orbital inflammatory conditions (n = 9 of 50; 18.0%): 5 patients (10.0%) were clinically diagnosed with giant cell arteritis, 3 (6.0%) with nonspecific orbital inflammation, and 1 (2.0%) with optic neuritis. In this subset of patients, 77.8% (n = 7 of 9) were treated initially with systemic steroids. Additional initial diagnoses included neoplastic mass lesions, mucocele, dacryocystitis, cavernous sinus thrombosis, hemorrhage, tick-borne illness, allergic rhinitis, and allergic conjunctivitis. Misdiagnosis was significantly correlated with involvement of the masticator space on imaging (p = 0.04). CONCLUSION Fungal infections of the orbit are misdiagnosed in 2 of 3 cases. Nearly 15% of patients who are later diagnosed with fungal disease of the orbit were initially treated with systemic steroids. Misdiagnosis is more frequent when the masticator space is involved.
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Affiliation(s)
- Brittany A Simmons
- From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Anna C Kupcha
- Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tenn
| | - James J Law
- Vanderbilt University School of Medicine, Nashville, Tenn
| | - Kai Wang
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Keith D Carter
- From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Louise A Mawn
- Vanderbilt University School of Medicine, Nashville, Tenn
| | - Erin M Shriver
- From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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Parija S, Banerjee A. Invasive fungal disease misdiagnosed as tumour in association with orbital apex syndrome. BMJ Case Rep 2021; 14:e237626. [PMID: 33472802 PMCID: PMC10577717 DOI: 10.1136/bcr-2020-237626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2021] [Indexed: 11/29/2022] Open
Abstract
Invasive sino-orbital aspergillosis is a rare cause of orbital apex syndrome (OAS) in immunocompetent patients and often misdiagnosed as tumour because of its aggressive nature and invasive patterns. We report a 23-year-old immunocompetent man presenting with painful progressive loss of vision, ophthalmoplegia and proptosis of the right eye suggestive of OAS. MRI with gadolinium contrast showed an enhancing heterogeneous mass filling the paranasal sinuses, extraconal space and extending up to the right orbital apex. A functional endoscopic biopsy reported as invasive sino-orbital aspergillosis. He was started on intravenous voriconazole and maximal surgical debridement was done. He gradually regained his vision to 20/30 in the right eye. A review of literature reported several such cases which were managed medically or surgically but with poor visual recovery. This case highlights the need for awareness among clinicians for early diagnosis and treatment to prevent vision loss and better survival.
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Affiliation(s)
- Sucheta Parija
- Ophthalmology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Aparajita Banerjee
- Ophthalmology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
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3
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A rare infective cause of stroke in an immunocompetent child. Brain Dev 2021; 43:152-156. [PMID: 32855000 DOI: 10.1016/j.braindev.2020.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Infections are a common cause of childhood stroke with variable presentation. The current case describes a rare infective cause of venous and arterial stroke in an immunocompetent girl with management implications. CASE DESCRIPTION A 12 year old girl, presented with history of fever for 10 days, painful swelling of right eye for 7 days and altered sensorium for 2 days. On examination, she had right eye orbital cellulitis and fullness of right paranasal area. On nervous system examination, she was delirious, had right eye ophthalmoparesis, left upper motor neuron facial palsy and signs of meningeal inflammation. Her contrast enhanced CT head and subsequent MRI brain with arteriography and venography revealed right cavernous sinus and distal internal carotid artery thrombosis. She was started on intravenous ceftriaxone and vancomycin and subcutaneous heparin. In view of persistent symptoms, endoscopic debridement of right nasal cavity was done, which showed growth of aspergillus flavus. Subsequently, she was started on intravenous voriconazole. Within a week, she was afebrile, her inflammatory and neurological signs started improving. She was discharged after 3 weeks of intravenous voriconazole which was continued for 3 more weeks orally. Her procoagulant and immunodeficiency work up were normal. At 4 months follow up, she showed both clinical and radiological resolution. CONCLUSIONS Despite high mortality described in sino-orbital aspergillosis, early and appropriate treatment led to optimal outcome. In deep seated infections, isolation of etiological organism should be attempted, particularly when patient doesn't respond to conventional antimicrobial therapy.
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Wu J, Zhou H, Wei R, Cheng J. Bilateral cellulitis caused by invasive aspergillosis associated with bilateral intraorbital abscesses: a case report. BMC Ophthalmol 2020; 20:330. [PMID: 32799822 PMCID: PMC7429779 DOI: 10.1186/s12886-020-01606-7] [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] [Received: 03/07/2020] [Accepted: 08/10/2020] [Indexed: 11/12/2022] Open
Abstract
Background Orbital invasive aspergillosis infection is rare life-threatening infection, most commonly seen in immunocompromised patients and extremely rare in individuals without risk factors. Here we present a rare case of bilateral cellulitis caused by invasive aspergillosis associated with bilateral intraorbital abscesses in a female patient. Case presentation A 49-year-old woman presented with a 3-month history of painful proptosis and periorbital swelling of bilateral eyes. She was initially diagnosed as bilateral orbital cellulitis complicated with cavernous sinus thrombosis and was treated with antibiotic medication for 1 month, but her symptoms persisted. MRI demonstrated orbital masses behind both globes. The lesion in right orbit was biopsied with a diagnosis of orbital granulomatosis with invasive aspergillosis infection. The patient was healed after receiving antifungal treatment. Conclusions This is an unusual case about bilateral orbital abscesses with invasive fungal infection. Fungal infection of the orbit should be considered when patient does not respond to combination of anti-inflammatory and antibiotic therapies, even in some cases without any risk factors.
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Affiliation(s)
- Jiahui Wu
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, National Clinical Research Center for Eye Diseases, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
| | - Hao Zhou
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, National Clinical Research Center for Eye Diseases, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
| | - Ruili Wei
- Department of Ophthalmology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jinwei Cheng
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, National Clinical Research Center for Eye Diseases, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China.
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5
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Yin LX, Spillinger A, Lees KA, Bailey KR, Choby G, O'Brien EK, Stokken JK. An internally validated diagnostic tool for acute invasive fungal sinusitis. Int Forum Allergy Rhinol 2020; 11:65-74. [PMID: 32668099 DOI: 10.1002/alr.22635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/29/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is a potentially life-threatening diagnosis in immunocompromised patients. Identifying patients who could benefit from evaluation and intervention can be challenging for referring providers and otolaryngologists alike. We aimed to develop and validate an accessible diagnostic tool to estimate the probability of AIFS. METHODS Retrospective chart review from 1999 to 2017 identified all patients evaluated for possible AIFS at a tertiary care center. AIFS was diagnosed by pathologic confirmation of fungal tissue angioinvasion. Stepwise selection and univariate logistic regression were used to screen risk factors for a multivariable predictive model. Model performance was assessed using Tukey's goodness-of-fit test and the area under the receiver operator characteristic curve (AUC). Model coefficients were internally validated using bootstrapping with 1000 iterations. RESULTS A total of 283 patients (244 negative controls, 39 with AIFS) were included. Risk factors in our final diagnostic model included: fever ≥38°C (log-odds ratio [LOR] 1.72; 95% CI, 0.53 to 2.90), unilateral facial swelling, pain, or erythema (LOR 2.84; 95% CI, 1.46 to 4.23), involvement of the orbit or pterygopalatine fossa on imaging (LOR 3.02; 95% CI, 1.78 to 4.26), and mucosal necrosis seen on endoscopy (LOR 5.52; 95% CI, 3.81 to 7.24), with p < 0.01 for all factors. The model had adequate goodness of fit (p > 0.05) and discrimination (AUC = 0.96). CONCLUSION We present an internally validated diagnostic tool to stratify the risk for AIFS. The estimated risk may help determine which patients can be observed with serial nasal endoscopy, which ones could be biopsied, and which ones would benefit from immediate surgical intervention.
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Affiliation(s)
- Linda X Yin
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN
| | - Aviv Spillinger
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN
| | - Katherine A Lees
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, UT
| | - Kent R Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Garret Choby
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN
| | - Erin K O'Brien
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN
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Asanad S, Lo C, Ugradar S, Rootman DB. Invasive cavernous sinus aspergillosis: an orbitocranial approach for diagnosis and management. Can J Ophthalmol 2019; 55:e33-e36. [PMID: 31712025 DOI: 10.1016/j.jcjo.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/07/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Samuel Asanad
- David Geffen School of Medicine, University of California, Los Angeles, USA.
| | - Christopher Lo
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, California, USA
| | - Shoaib Ugradar
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, California, USA
| | - Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, California, USA
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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
Fungal infections of the orbit can lead to grave complications. Although the primary site of inoculation of the infective organism is frequently the sinuses, the patients can initially present to the ophthalmologist with ocular signs and symptoms. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. Ophthalmologists should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of this invasive sino-orbital infection. In this review, relevant clinical, microbiological, and imaging findings are discussed along with the current consensus on local and systemic management. We review the recent literature and provide a comprehensive analysis. In the immunocompromised, as well as in healthy patients, a high index of suspicion must be maintained as delay in diagnosis of fungal pathology may lead to disfiguring morbidity or even mortality. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly oral voriconazole and topical amphotericin B, may be beneficial in selected patients.
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Affiliation(s)
- Bipasha Mukherjee
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Nirav Dilip Raichura
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Md Shahid Alam
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
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10
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Baeesa SS, Bakhaidar M, Ahamed NAB, Madani TA. Invasive Orbital Apex Aspergillosis with Mycotic Aneurysm Formation and Subarachnoid Hemorrhage in Immunocompetent Patients. World Neurosurg 2017; 102:42-48. [PMID: 28254599 DOI: 10.1016/j.wneu.2017.02.096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/18/2017] [Accepted: 02/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Invasive orbital apex aspergillosis (IOAA) is an aggressive form of aspergillus infection that usually affects immunocompromised patients. It can cause orbital apex syndrome and, if not treated promptly, may progress rapidly causing fatal complications. Subarachnoid hemorrhage (SAH) secondary to ruptured mycotic aneurysms is a very rare complication of invasive aspergillosis. We aim to describe our management and the outcome of six immunocompetent patients with IOAA with subsequent SAH secondary to ruptured mycotic aneurysms. PATIENTS AND METHODS A retrospective review was undertaken of charts of patients treated for orbital involvement with aspergillosis between January 2003 and December 2015 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. We identified all immunocompetent patients with IOAA who developed vascular complications. RESULTS Six immunocompetent patients with IOAA complicated by SAH secondary to ruptured mycotic aneurysms were identified in the study period. Four patients were female, and patients' age ranged between 14 and 53 years (mean, 33.7 ± 13.4 years). All patients presented with progressive retro-orbital headache, visual impairment, and ophthalmoplegia; four had proptosis. Two patients had vasospasm and brain infarction. Antifungal therapy was used in all patients, and 4 underwent emergency craniotomy and clipping of an aneurysm. Five patients died as a consequence of SAH and infarction. CONCLUSIONS IOAA is a serious disease that commonly causes catastrophic and fatal vascular complications.
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Affiliation(s)
- Saleh S Baeesa
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Mohamad Bakhaidar
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Naushad A B Ahamed
- Department of Radiology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tariq A Madani
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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11
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Seven cases of localized invasive sino-orbital aspergillosis. Jpn J Ophthalmol 2017; 61:179-188. [PMID: 28097453 DOI: 10.1007/s10384-016-0494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To describe the clinical manifestations and prognoses in 7 patients with invasive sino-orbital aspergillosis (ISOA). METHODS This was a retrospective study of consecutive patients who were diagnosed as having ISOA at the Gifu University Hospital and Gifu Municipal Hospital between January 1993 and December 2015. Data were collected on demographics, initial manifestations, examination findings, treatments, clinical course, and outcomes. RESULTS The median age of the 7 patients with ISOA was 68 years; 5 of them had diabetes. The initial symptoms were reduced blurred vision (57%), unilateral headaches (43%), unilateral abnormal sensations or numbness of the periorbital area (43%), and external ophthalmoplegia (43%). The medical department that the patients first visited was the ophthalmology department in 57% of the cases. The initial CT showed bone destruction in 71% and calcification in 14% of the patients. Six of the 7 cases were misdiagnosed. The definitive diagnosis of ISOA was made by histopathologic examinations of the biopsy specimens, with an average of 2.6 biopsies. All patients received aggressive antifungal treatments after the diagnosis. However, the final visual outcome was no light perception in 86% and death related to the ISOA in 43% of the patients. Patients who were older at the onset had lower survival rates. CONCLUSIONS The prognosis for patients with ISOA is poor in terms of both vision and life. Ophthalmologists are often the first examiner. ISOA should be considered in the differential diagnosis for patients with a gradually progressive orbital mass, unilateral headaches, numbness of the periorbital area, and a decrease in visual acuity of unknown origin.
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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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Neil JA, Orlandi RR, Couldwell WT. Malignant fungal infection of the cavernous sinus: case report. J Neurosurg 2015; 124:861-5. [PMID: 26315007 DOI: 10.3171/2015.2.jns142668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial spread of fungal infection is a life-threatening condition that usually affects immunocompromised patients. Here the authors present a case of biopsy-proven Aspergillus fumigatus infection of the paranasal sinuses in an immunocompetent patient with documented spread to the orbit, cavernous sinus, and petrous apex despite medical antifungal treatment. As a life-saving treatment, cavernous sinus resection with external carotid artery-middle cerebral artery bypass was performed. The authors discuss the literature regarding the intracranial spread of paranasal sinus fungal infections in immunocompetent patients and management strategies.
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Affiliation(s)
| | - Richard R Orlandi
- Department of Surgery, Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah
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Trief D, Gray ST, Jakobiec FA, Durand ML, Fay A, Freitag SK, Lee NG, Lefebvre DR, Holbrook E, Bleier B, Sadow P, Rashid A, Chhabra N, Yoon MK. Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus. Br J Ophthalmol 2015; 100:184-8. [PMID: 26112869 DOI: 10.1136/bjophthalmol-2015-306945] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/30/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS Invasive fungal infections of the head and neck are rare life-threatening infections where prompt diagnosis and intervention is critical for survival. The aim of this study is to determine the clinical characteristics and outcomes of invasive fungal disease of the sinus and orbit, and to compare mucormycosis and Aspergillus infection. METHODS A retrospective review was conducted from a single tertiary care eye and ear hospital over 20 years (1994-2014). Twenty-four patients with a confirmed pathological diagnosis of invasive fungal disease of the sinus and/or orbit were identified and their medical records were reviewed. The main outcome measures were type of fungus, location of disease, mortality and visual outcome. RESULTS Patients with orbital involvement had a higher mortality and higher likelihood of mucormycosis infection compared with those with sinus-only disease (78.6% vs 20%, p=0.01; 86% vs 30%, p=0.01, respectively). Patients with mucormycosis had a higher mortality (71%) than patients with Aspergillus (29%); however, this was not statistically significant (p=0.16). All patients with orbital involvement and/or mucormycosis infections were immunosuppressed or had inadequately controlled diabetes, and had a cranial neuropathy or ocular motility dysfunction. All five post-transplant patients with orbital infections died, while the two transplant patients with sinus infections survived. CONCLUSIONS Patients with orbital fungal infections are more likely to be infected with mucormycosis compared with Aspergillus and have a higher mortality compared with infections sparing the orbit. History of transplant portends a dismal prognosis in orbital infections. Invasive fungal disease should be considered in any immunocompromised patient presenting with a new cranial neuropathy or ocular motility abnormality.
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Affiliation(s)
- Danielle Trief
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey T Gray
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Frederick A Jakobiec
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Marlene L Durand
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron Fay
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne K Freitag
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - N Grace Lee
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Holbrook
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Bleier
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Sadow
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Alia Rashid
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Nipun Chhabra
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Yoon
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, 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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Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease. Ophthalmic Plast Reconstr Surg 2013; 29:e69-72. [PMID: 23128539 DOI: 10.1097/iop.0b013e318272d480] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The clinical presentation and course of orbital cellulitis in a young adult resulting from Arcanobacterium hemolyticum frontal sinusitis are presented in detail. This case illustrates the importance of a multidisciplinary approach for refractory and aggressive orbital cellulitis. A high level of suspicion for A. hemolyticum must be maintained in such cases, because it has proven to be a rare but aggressive, potentially occult, and life-threatening pathogen.
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Kim SJ, Kim CR, Kim GN, Han YS, Chung IY, Seo SW, Park JM, Yoo JM. A Case of Invasive Aspergillosis Presenting as Acute Angle Closure Glaucoma. Neuroophthalmology 2013; 37:31-34. [PMID: 28163753 DOI: 10.3109/01658107.2012.753912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 11/13/2022] Open
Abstract
Purpose: To report a case of invasive aspergillosis presenting as acute angle closure glaucoma. Case: A 72-year-old male patient visited our clinic with decreased visual acuity and ocular pain on the right eye lasting for 3 d. His intraocular pressure was 42 mmHg in the right eye and 18 mmHg in the left eye. And, there was about 2 mm of exophthalmos, slight ptosis with decreased motility in all directions, conjunctival injection, moderate mydriasis with a relative afferent pupillary defect, and angle closure in the right eye. Orbital computed tomography and magenetic resonance imaging showed isotense mass involving right orbit and ethmoid sinus. Based on the biopsy, invasive aspergillosis was definitely diagnosed. Despite perfoming peripheral laser iridotomy and administrating antifungal agent and antiglaucoma medication, the patient was blinded in his right eye. During the follow-up period, visual acuity in the left eye suddenly decreased due to the invasive aspergillosis in the left paranasal sinus and optic nerve, and eventually the patient lost his left vision as well. Conclusion: This report is regarding a case of an invasive aspergillosis resulting in blindness in both eyes with the clinical manifestations of acute angle closure caused by invasive aspergillosis.
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Affiliation(s)
- Seong-Jae Kim
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
| | - Che-Ron Kim
- Department of Ophthalmology, College of Medicine
| | - Gyu-Nam Kim
- Department of Ophthalmology, College of Medicine
| | - Yong-Seop Han
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
| | - In-Young Chung
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
| | - Seong-Wook Seo
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
| | - Jong-Moon Park
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
| | - Ji-Myong Yoo
- Department of Ophthalmology, College of Medicine; Gyeongsang Institute of Health Science, Gyeongsang National UniversityJinjuKorea
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Chan JCW, Yu DKH, Lee DLY, Abdullah VJ, Li KKW. Combined lateral orbitotomy and endoscopic transnasal orbital decompression in a case of orbital aspergillosis with impending intracranial invasion. Case Rep Ophthalmol 2013; 3:418-23. [PMID: 23341818 PMCID: PMC3551432 DOI: 10.1159/000346043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 64-year-old man with a known history of diabetes and hypertension presented to the Accident and Emergency Department with a 2-day history of sudden decreased vision in the right eye. Temporal arteritis was suspected with an elevated erythrocyte sedimentation rate (71 mm/h), and oral prednisolone was started immediately. Four days later, the patient's right eye vision deteriorated from 0.6 to 0.05, with a grade-4 relative afferent pupillary defect and ophthalmoplegia. Computed tomography showed a contrast-enhancing orbital apex mass in the right orbit abutting the medial and lateral portions of the optic nerve with extension to the posterior ethmoid and sphenoid sinuses. A transethmoidal biopsy was performed which yielded septate hyphae suggestive of Aspergillus infection. Ten days later, the patient's right eye vision further deteriorated to hand movement with total ophthalmoplegia. MRI of the orbit showed suspicion of cavernous sinus thrombosis. A combined lateral orbitotomy and transethmoidal orbital apex drainage and decompression were performed to eradicate the orbital apex abscess. Drained pus cultured Aspergillus. The patient was prescribed systemic voriconazole for a total of 22 weeks. The latest MRI scan, performed 8 months after surgery, showed residual inflammatory changes with no signs of recurrence of the disease. To our knowledge, this is the first case report which describes the use of a combined open and endoscopic approach for orbital decompression and drainage in a case of orbital aspergillosis. We believe the combined approach gives good exposure to the orbital apex, and allows the abscess in this region to be adequately drained.
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Affiliation(s)
- Jeffrey C W Chan
- Department of Ophthalmology, United Christian Hospital, Affiliated Unit of the Chinese University of Hong Kong, Hong Kong, SAR, China
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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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Naik SR, Thakare VN, Desai SK, Rahalkar PR. Study of immunological aspects of aspergillosis in mice and effect of polyene macrolide antibiotic (SJA-95) and IFN-γ: A possible role of IFN-γ as an adjunct in antifungal therapy. Immunol Lett 2011; 141:68-73. [DOI: 10.1016/j.imlet.2011.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 07/14/2011] [Accepted: 07/25/2011] [Indexed: 10/17/2022]
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