Purpose: Following previous hospitalization and clinical assessment at a District General Hospital, a 37 year-old male patient presented in the maxillofacial out-patient clinic with uncontrolled diabetes mellitus (315 mg/dl) headache, erythema, left cheek and eyelid swelling and with an initial zygomycosis diagnosis. Methods: Clinical examination showed a palatal ulcer and left side blepharoptosis. Three days later the patient presented left eye blindness. CT scan demonstrated areas of signal heterogeneity in the left maxillary and sphenoid sinus and extension of disease into adjacent anatomic areas. Subsequent histological and Microbiological examination MRI of guided fine needle aspirate form the affected sinus was negative for fungi, yet, due to the underlying Diabetes, i.v liposomal amphotericin B at 4 mg/kg per day in two dosages was administered for 12 weeks to cover for possible zygomycosis. Due to the patient’s stable, yet not improving condition, and as zygomycosis had not been proven, a second biopsy of the left maxillary sinus was performed and showed presence of a septate filamentous fungus. Further non-culture tests were positive for galactomannan antigen, beta glucan (Fungitell® ) with titre >100 pg/ml, while whole blood real time PCR was positive for Aspergillus sp. Following assessment of the positive second biopsy, the positive galactomannan and beta glucan tests, zygomycosis was excluded and the patient was immediately administered posaconazole 400 mg X 2 p.o. with concomitant surgical debridement of the left maxillary sinus. Upon evaluation of our patient’s history, posaconazole was preferred due to its limited reported side effects. Results: Cultures of the biopsy material subsequently grew Aspergillus Section Fumigati. ITS and partial beta tubulin (primers Bt2a/Bt2b) sequencing confirmed the isolate’s identity as A. fumigatus with low azole MICs (>= 0.5 μg/ml) and MECs of caspofungin 0.25 μg/ml, micafungin 0.12 μg/ml and anidulafungin 0.5 μg/ml. Posaconazole at 400 mg X 2 as administered p.o. for a total of 12 months with concurrent serum level monitoring for galactomannan and beta glucan, which showed progressive titre decrease. Six months after the onset of the therapy, all non-culture tests were negative, while a new CT scan showed improvement in all previously affected anatomical sites. Conclusions: This case highlights the complexity in diagnosing Aspergillus paranasal sinusitis. Clinicians should include this disease in their differential diagnosis in patients with diabetes mellitus.
Full conference title:
4th Advances Against Aspergillosis
- AAA 4th (2010)