Limited superficial invasion as an early manifestation of acute invasive fungal sinusitis

Abstract

Objective: To describe a case of acute invasive fungal sinusitis (AIFS), unique in its presentation with limited superficial invasion, underlying a fungal crust, in a patient on antifungal prophylaxis. To present accompanying images and pathology results that capture the very early stages of fungal invasion and depict the ongoing battle between fungal organisms and the immune system. Methods: Case report with literature review. Results: We present the case of a 74-year-old immunocompromised male on prophylactic voriconazole who was admitted with neutropenic fever and was found to have superficially invasive fungal sinusitis. Pathology from the initial surgical debridement showed superficial invasion of the middle turbinate mucosa, but no angioinvasion. Biopsies from a second surgical debridement were negative for fungal organisms, but fungal cultures were positive. The patient was treated with amphotericin B and posaconazole and discharged with plans for likely lifelong posaconazole. Conclusion: This case augments the existing AIFS literature in that the histopathology uniquely demonstrates limited superficial invasion, underlying a fungal crust, likely portraying the early stages of AIFS. Additionally, this case highlights new and ongoing clinical questions surrounding AIFS prevention and diagnosis, particularly in immunocompromised patients.

Keywords

• Sinusitis
• Invasive fungal infections
• Antifungal agents
• Alternaria