Scedosporium Sinusitis: A Rare Opportunistic Infection

Abstract

Scedosporium sinusitis is an opportunistic fungal infection that is difficult to treat due to its inherent resistance to many antifungal agents. Infections may cause both localized or disseminated disease usually in skin and soft tissues. Immunocompetent persons are typically unaffected and disseminated disease occurs in immunocompromised hosts. Scedosporiumis a common hyaline mold causing sinopulmonary disease in those with hematologic malignancies and neutropenia. A 38-year-old Caucasian male with a medical history significant for HIV with intermittent treatment compliance, high-grade diffuse large B cell lymphoma (DLBCL) on chemotherapy, and hemophagocytic lymphohistiocytosis (HLH) presented with right-sided facial pain and fever. Maxillofacial computed tomography (CT) showed thickening and opacification of the sphenoid and maxillary sinuses concerning for fungal sinusitis. Endoscopic transsphenoidal debridement showed fungal growth of Scedosporium and the patient's blood cultures were ultimately negative. The patient underwent debridement of fungal sinusitis as well as right medial maxillectomy and ethmoidectomy. A three-month course of voriconazole was started and completed with weekly liver enzyme tests to monitor medication side effects. He has since been observed well as an outpatient with his oncologist after three months loss to follow-up and his infection has resolved.

Keywords: ent procedures; hemophagocytic lymphohistiocytosis (hlh); human immunodeficiency viruses (hiv); infections in neutropenic fever; infectious disease pathology; invasive fungal sinusitis; maculopapular rash; opportunistic fungal infection; scedosporium; scedosporium sinusitis.

Figure 1. Initial CT maxillofacial with contrast

Findings concerning for invasive fungal sinusitis with near complete opacification of the right sphenoid sinus (yellow arrow).

Figure 2. MRI orbit face and neck with contrast

Findings show right sphenoethmoidal fungal sinusitis (yellow arrows). There is infection and an 8 mm sinonasal polyp in the right sphenoethmoidal recess/posterior superior nasal canal.

Figure 3. Maculopapular rash (black arrows) on presentation to emergency department with circular and serpiginous distribution and central clearing (yellow arrow) and scale on the right arm.

Figure 4. Repeat CT maxillofacial on day 7 of admission

(A) Postsurgical changes with partial ethmoidectomy and sphenoidectomy. Soft tissue obstruction of contralateral left sphenoid sinus (blue arrow); (B) Abscess of #12 (yellow arrow is enhanced over radiologist’s indicator).

Figure 5. Repeat MRI orbit face and neck (without contrast) on day 8 of admission showing now absent dentition (thin yellow arrows) as well as postoperative changes (thick yellow arrow).