Date: 26 November 2013
Nasal, sinus and orbital aspergillosis in a cat. The left nasal cavity and sinus were full of pus and debris and there was severe bone erosion from the nasal cavity into the rostromedial orbitthrough which pus was protruding
Copyright:
(Kindly provided by Martin L. Whitehead, BSc, PhD, BVSc, CertSAM, MRCVS & Peter W. Kettlewell, BVSc, MSc, MRCVS. Chipping Norton Veterinary Hospital, Albion Street, Chipping Norton, Oxon, OX7 5BN.)
Notes:
History : Nasal aspergillosis is relatively common in dogs but rare in cats. Our veterinary hospital in Oxfordshire was recently presented with a 13-year old female Burmilla cat with a history of left-side unilateral nasal discharge, a watery left eye with slight blepharospasm, occasional ‘twitching movements’ of the head, weight loss, inappetance and depression. Clinical examination was unremarkable except for left-side mucopurulent nasal discharge, left-side mild serous ocular discharge, and a soft subcutaneous swelling over the left frontal sinus. Haematology, blood biochemistry and urinalysis revealed diabetes mellitus but was otherwise unremarkable. Radiography under general anaesthesia revealed a diffuse soft tissue density within the left nasal cavity and left frontal sinus. Rhinoscopy revealed mucopurulent discharge on the left side but was otherwise unremarkable. Aspiration of the swelling over the left frontal sinus produced pus and this abscess was lanced and flushed. The frontal sinus was trephined and the sinus and nasal cavity flushed with saline. Tests for feline immunodeficiency virus and feline leukaemia virus and serology for Aspergillus were not carried out. The cat was started on insulin, ibafloxacin (Ibaflin, Intervet) and meloxicam (Metacam, Boehringer). Cytology of the material flushed from the frontal sinus and nasal cavity revealed fungal hyphae consistent with Aspergillus species and culture of this material yielded growth of a fungus which was morphologically similar to A. candidus (Awaiting molecular typing results). The cat was then started on oral itraconazole (Itrafungol, Janssen) 10 mg/kg p.o. SID. The abscess over the rostral frontal sinus did not heal and a second abscess appeared over the nasal bone just dorsal to the nose. Infusion of the frontal sinus and nasal cavity with topical antifungal medication was discussed with the owners, but as the cat was deteriorating they requested euthanasia. On post-mortem examination the right nasal cavity, frontal sinus and orbit were unaffected. The left nasal cavity and sinus were full of pus and debris and there was severe bone erosion from the nasal cavity into the rostromedial orbit through which pus was protruding. There was also severe bone erosion rostrally through the nasal bone and less severe bone erosion dorsally over the rostral part of the frontal sinus, these sites of bone erosion being at the location of the two subcutaneous abscesses.Feline nasal aspergillosis is extremely rare in the UK and to our knowledge this is the first reported case of orbital aspergillosis in the UK although nasal aspergillosis has been reported in other countries.
Images library
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25/04/90 After itraconazole treatment. Major improvement, defined as a complete response, after 10 weeks therapy with itraconazole.
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Image A. Chest x-ray shows a single nodule in the left mid lung field.
Image B. This emphasises how chest x-rays in this context underestimate the extent of disease. The most anterior nodule has ground glass surrrounding the nodule, a halo sign. This diagnostic feature is missed on plain chest X-rays.
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Chest X ray after 4 days, prior to treatment, showing massive increase in volume of lesion (Fig 2)
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Image A. This patient, aged 25 years developed a non productive cough and dyspnoea in the context of late-stage AIDS, CMV disease with ganciclovir-induced neutropenia and receiving corticosteroids. His chest radiograph shows fine bilateral reticular lower-lobe shadowing. He then developed gastro-intestinal bleeding with a gastric ulcer which showed hyphae on biopsy. He then developed blindness of one eye and the globe of his eye perforated. Hyphae were seen and Aspergillus cultured from the vitreous aspirate.
Image B. This radiograph, taken 25 days after the first and 3 days before death, shows of fine bilateral lower-lobe reticular shadows progressing to nodules in all lung zones.
This patient was reported as patient 3 in Denning DW, Follansbee S, Scolaro M, Norris S, Edelstein D, Stevens DA. Pulmonary aspergillosis in the acquired immunodeficiency syndrome. N Engl J Med 1991; 324: 654-662.
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Further details
Image A. Bronchoscopy revealed Aspergillus on culture.
Image B. The ability of Aspergillus to cause pulmonary infarction, probably through direct angioinvasion in this case, is characteristic.
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(Fig 1) Chest radiograph with ‘classical’ appearance of a pulmonary infarction – a wedge-shaped lesion peripherally set against the pleura.
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Large soft left upper-lobe shadow of focal invasive pulmonary aspergillosis in leukaemia, that was missed on earlier radiographs but apparent retrospectively. Variable density of the lesion suggests cavitation, which would be clearly visible on a CT scan of the thorax.
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Severe unilateral invasive aspergillosis of the left lung, with complete consolidation of the left lower-lobe and reticular shadowing extending up into the left upper lobe. The right lung appears normal.
