Orbital aspergillosis with late fungemia

Submitted by: Michael on: 16 April 2013

Case number: 43

Summary:

This patient (age 76) developed pain and swelling around the right eye which got progressively worse. She had a history of temporal arteritis (1988), which required high doses of prednisone. CAT scan and MRI demonstrated a right orbital mass on both sides of the lateral orbital wall that extended to and invaded the soft tissues of the right infra-temporal fossa. Small additional lesions were noted in the left mastoid region on the right and in the left cerebellum. The mass was biopsied and revealed extensive inflammation. Special stains and cultures were all negative for acid fast bacilli, fungi and bacteria. A sputum culture taken at that time was positive for Aspergillus fumigatus and she was commenced on amphotericin B – 500mg.

She was discharged and continued on 50 mg/day amphotericin B which she failed to tolerate. On readmission she had developed new scattered infiltrates on her chest X-ray and a CT scan showed numerous patchy areas of inflammation without cavitation. A bronchoscopy revealed a neutrophilic alveolitis with negative microscopy and culture. She developed Staphylococcus aureus pneumonia following bronchoscopy. A total dose of amphotericin B of 1.510mg was administered and all of her eye symptoms resolved. Ophthalmological review showed 20/40 vision in both eyes, slight right VIth nerve palsy, or lateral rectus nerve dysfunction which was thought likely to resolve. She was discharged again and continued on 35 mg amphotericin B daily for 2 weeks.

A month later she was admitted with further orbital and maxillary swelling, visual loss and a left seventh nerve palsy, 2 weeks after stopping amphotericin B. Repeat MRI showed extension of the lesions in the left mastoid region and in the left cerebellopontile angle. Admission blood culture yielded A. fumigatus. Total parenteral nutrition was instituted, and 900mg of amphotericin B was administered. The prednisone dose was increased to 10mg daily and she gradually improved. A repeat MRI scan of the area showed no change however. The patient decided to go home, and was given oral itraconazole (on trial) 400mg/d for two weeks and then declined any further treatment.

Keywords: orbital aspergillosis, amphotericin B, itraconazole, temporal arteritis

Species (if applicable): Aspergillus fumigatus

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