Localised invasive sino-orbital aspergillosis: characteristic features

Abstract

Background/aim: To describe the characteristic constellation of historical, clinical, radiographic, and histopathological findings of localised invasive sino-orbital aspergillosis based on the authors' recent experience of four consecutive cases presenting over a 6 month period. Treatment and outcome are reviewed.

Methods: A case series of four patients with review of the English language literature.

Results: There have been 17 reported cases of invasive sino-orbital aspergillosis in healthy individuals over the past 33 years. The authors report four patients who presented during a 6 month period with persistent and significant pain followed by progressive ophthalmic signs-clinical histories reflecting the literature. Similar imaging findings were also noted: focal hypodense areas within apical infiltrates on contrasted computed tomography correspond to abscesses seen at surgery, and sinus obliteration or involvement of the adjacent sinus lining was noted on magnetic resonance imaging. Bone erosion (often focal) was also seen. There is frequently a delay in making the correct diagnosis, and often disease progression occurs despite treatment.

Conclusions: The authors encountered four cases of invasive sino-orbital aspergillosis, three of which occurred in otherwise healthy individuals. The clinician must be aware of the characteristic presentation so that earlier diagnosis, management, and improved outcomes can be achieved.

Figure 1

Case 1. (A) Axial computed tomography (CT) shows lesion located in the left apical orbit (arrow), and (B) axial T1 weighted MRI with gadolinium and fat suppression performed 1 week later shows the focal sinus lining enhancement (arrow) and extension of the lesion into adjacent tissue. (C) Axial CT 6 weeks after presentation shows stabilisation of the mass. Seven months after initial presentation, repeat CT (D) shows increase in size of the lesion and the presence of a brain abscess in the left temporal lobe (arrow). (E) Grocott stain of aspergillus organism (original magnification ×250). (F) Vascular invasion (haematoxylin eosin, original magnification ×100). (G) Bony invasion by aspergillus organisms (arrows) (haematoxylin eosin, original magnification ×100).

Figure 2

Case 2. (A) Axial computed tomography (CT) before referral shows sphenoid sinus (arrow)/orbital apical lesion. (B) Axial CT performed 4 months later shows enlargement of the lesion with a focal low density abscess (arrow). (C) Axial and (D) coronal scans performed 8 months after diagnosis shows stabilisation of the lesion.

Figure 3

Case 3. (A) An apical lesion can be seen on axial computed tomography (CT). Note the bony defect in the sphenoid sinus (arrow). (B) Coronal T1 weighted MRI performed 1 month later shows focal sphenoid sinus lining enhancement (arrow). (C) Axial CT before biopsy shows that the lesion has enlarged in size. Focal abscesses (arrows) can also be noted. Two months after diagnosis, follow up CT (D) shows further enlargement of lesion and 6 months later, a brain abscess was noted (E).