Chronic Invasive Fungal Sinusitis Mimicking Malignancy Post-Radiotherapy: A Case Report

Abstract

Invasive fungal sinusitis is a life-threatening form of fungal rhinosinusitis. Due to the aggressive clinical presentation and radiological appearance, there is diagnostic difficulty in differentiating invasive fungal sinusitis from a malignant process. This is even more challenging in oncological patients who have undergone previous head and neck radiotherapy, due to possibility of a recurrence of primary malignancy and radiation-induced neoplasms. We report a rare case of invasive fungal sinusitis mimicking a malignancy in a post-radiotherapy patient. Our patient was a 68-year-old male, 25-years post-radiotherapy for nasopharyngeal carcinoma. He presented with a 3-month history of purulent sputum and right facial paraesthesia. Magnetic resonance imaging showed an irregular destructive enhancing mass of the greater wing of right sphenoid and pterygoid bone with extensive extension into nearby structures. In view of extensive local and bony invasion, and a history of radiotherapy, initial suspicions were that of primary malignancy, specifically radiation-induced sarcoma, and recurrence of nasopharyngeal carcinoma. He underwent transpterygoid biopsy of the lesion, and histopathology demonstrated Aspergillus species, with no malignancy identified. Our report highlights the diagnostic difficulties in the post-radiotherapy cancer patient presenting with symptoms suggestive of aggressive sino-nasal disease. Invasive fungal sinusitis closely mimics the clinical and radiological findings of several neoplastic processes. We discuss the clinical and radiological characteristics of pathologies that may mimic invasive fungal sinusitis. Histological examination remains the gold standard for diagnosis, and early fungal staining is crucial. Furthermore, one should not presume the initial histopathological diagnosis to be confirmatory of isolated fungal disease. Repeat radiological investigations for disease resolution and histopathologic re-evaluation if required should be performed, keeping in mind possibility of coexisting malignancy.

Keywords: Aspergillosis; Carcinoma; Fungal sinusitis; Radiotherapy; Sarcoma.

Fig. 1

A CT Paranasal sinuses: Destructive lesion of the greater wing of right sphenoid and pterygoid bone (green arrows). B T1 MRI paranasal sinuses (post-contrast): Enhancing mass of the pterygopalatine fossa with middle cranial fossa, temporal bone, lateral pterygoid and temporalis muscle invasion (yellow arrow); Invasion of the Right orbit (red arrow)

Fig. 2

Within Right Maxillary Sinus; via endoscopic maxillary mega-antrostomy. A Within Right Maxillary Sinus, intact posterior wall mucosa. B Purulent material (white arrow) on dissection of Right PPF. *Posterior wall, † Roof