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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 862-863
Invasive fungal sinusitis resulting in orbital apex syndrome in HIV patient


Department of Microbiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai-400 002, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Baradkar V P, Mathur M, Kumar S. Invasive fungal sinusitis resulting in orbital apex syndrome in HIV patient. Indian J Pathol Microbiol 2010;53:862-3

How to cite this URL:
Baradkar V P, Mathur M, Kumar S. Invasive fungal sinusitis resulting in orbital apex syndrome in HIV patient. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Nov 24];53:862-3. Available from: https://www.ijpmonline.org/text.asp?2010/53/4/862/72009


Sir,

Pseudoallescheria boydii, a ubiquitous saprophytic fungus, is an emerging pathogen found worldwide. It is commonly isolated in soil, polluted and coastal waters and animal manure. [1] This pathogen is associated with Madura foot. The organism has also been identified in specimens from pulmonary cavities, infiltrates and has been shown to cause sinusitis and disseminated infection. [1],[2],[3],[4] We report a case of invasive fungal sinusitis leading to eye involvement and resulting in orbital apex syndrome in a 56-year-old HIV seropositive male patient successfully treated with voriconazole.

The patient, a known HIV-1 seropositive male, presented with a six-month history of mass in nose, headache and repeated epistaxis. Diagnosed as a case of sinusitis, he was treated with amoxicillin plus clavulanic acid combination in a private hospital. But the headache did not subside. On admission in our hospital, the patient presented with ptosis, diminished vision, headache, retroorbital pain, epistaxis and poypoid mass in the nose. His CD 4 count was 100/μl. His liver and kidney function tests were within normal range. He was nondiabetic. On examination there was a polypoid growth in the left nasal cavity. The patient was anicteric; mild pallor was present and there was no associated lymphadenopathy. The liver and spleen were not palpable. The respiratory, central nervous system (CNS) and cardiovascular system were within normal limits. The patient had a past history of pulmonary tuberculosis (two years ago), treated successfully with antitubercular therapy.

Computerised tomography (CT) scan of the nose and paranasal sinuses showed a "fungus ball" like swelling in the nose [Figure 1] spreading to involve the eye, along with swelling in periorbital areas. The frontal lobes and cavernous sinuses showed normal appearance. Biopsy samples were collected from the mass and processed for 10% KOH mount, gram staining, hematoxylin and eosin (H and E) staining and Gomori's methanamine silver staining (GMS). Septate fungal hyphae were seen in 10% KOH preparation and gram stained smear. On this provisional report, the patient was started on voriconazole treatment. The (H and E) stained smear along with the GMS stained smears showed septate fungal hyphae. The biopsy sample was cultured on Sabouraud's Dextrose agar (SDA) with and without antibiotics and incubated at 22°C and 37°C respectively. The colonies which were initially creamish yeasty became cottony grayish after seven days of incubation [Figure 2]. Lactophenol cotton blue (LPCB) preparation was performed from the colony which showed septate hyphae and conidiophore bearing conidia at the tip giving a typical "lollypop appearance" [Figure 3] suggestive of Pseudoallescheria boydii.
Figure 1: CT scan of paranasal sinus showing polypoidal mass in left nasal and paranasal cavity

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Figure 2: Colony of Pseudoallescheria boydii on SDA

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Figure 3: LPCB from colony of Pseudoallescheria boydii on SDA showing septate hyphae, conidiophore with conidia at tip showing "lollipop" appearance

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After surgical debridement, the headache and retroorbital pain subsided. There was no further deterioration and hence no spread of infection to brain, a well known complication of rhino-orbital disease. Fungal sinusitis is rarely reported in AIDS (acquired immunodeficiency syndrome) and typically occurs at CD 4 counts below 150 cells/μl. Fungi reported to cause fungal sinusitis in AIDS patients include Aspergillus species, Schizophyllum commune, Cryptococcus neoformans, Candida albicans, Rhizopus arrhizhus and Alternaria alternate and Pseudoallescheria boydii.[2] There are 26 cases of fungal sinusitis due to Pseudoallescheria boydii described in literature. [1],[2],[3],[4],[5] Chronic invasive fungal sinusitis may be associated with "orbital apex syndrome" - the infection reaches orbital apex resulting in decreased vision, impaired ocular mobility and ptosis, as in the present case. Identification of Pseudoallescheria boydii by fungal culture is essential to select an effective therapy as it is resistant to amphotericin B; voriconazole may be required to treat such cases.

 
   References Top

1.Travis LB, Robert GD, Wilson SR. Clinical significance of Pseudoallescheria boydii: A review of 10 years experience. Mayo Clinic Prac 1985;60:531-7.  Back to cited text no. 1
    
2.Mayer RD, Lawtier CR, Yamashita JT. Fungal sinusitis in patients with AIDS: Reports of 4 cases and review of literature. Medicine 1994;73:69-78.   Back to cited text no. 2
    
3.Horton CK, Haug L, Gooze L. Pseudoallescheria boydii infections in AIDS. J Acquir Immuno Defic Syndr Hum Retroviraol 1999;20:200-11.  Back to cited text no. 3
    
4.Hecht R, Montgomeire JZ. Maxillary sinus infection with Allescheria boydii. Johns Hopkins Med J 1978;239:2368-9.  Back to cited text no. 4
    
5.Mohr JA, Muchmore HG. Susceptibility of Allescheria boydii to Amphotericin B. Antimicrobial Agents Chemother 1968;30:42.  Back to cited text no. 5
    

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Correspondence Address:
V P Baradkar
Department of Microbiology, L.T.M.M.C and L.T.M.G.H, Sion, Mumbai-400 022
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72009

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  [Figure 1], [Figure 2], [Figure 3]



 

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