Abstract
Background
Invasive fungal infections (IFIs) are uncommon infections that account for approximately 27.2/100,000 cases per year in the United States. One form of IFI is chronic invasive fungal sinusitis (CIFS). If untreated, invasion into neighboring structures may cause altered mental status, seizures, strokes, proptosis, and intracranial complications.
Case Report
An afebrile 43-year-old female with a history of polysubstance abuse presented to the ED due to altered mental status, left sided facial droop, right sided hemiparesis, and slurred speech. The patient was somnolent but arousable to stimuli and appeared acutely ill. The patient’s mother reported a history of cocaine abuse, which was confirmed on urine toxicology. A CT head and neck with contrast revealed subacute basal ganglia lacunar infarcts and a left sphenoid opacity with scattered hyperintensities and erosive changes [Figure 2]. One month prior, she had been diagnosed with a left superior pole kidney mass and a left-sided enlarged periaortic lymph node containing multiple noncaseating granulomas and GMS stains positive for fungal hyphae [Figure 1].
The patient underwent nasal endoscopy with tissue biopsy. Tissue showed necrotizing invasive fungal sinusitis with granuloma formation and foreign-body giant cell reaction. Fungal speciation of the tissue culture showed Curvularia species was placed on IV voriconazole. While the infection stabilized, her neurologic deficits did not significantly improve. She was discharged to inpatient rehabilitation.
Figure 1. Coronal and axial view of left upper pole kidney mass with perinephric fat stranding.
Figure 2. MRI brain CTA Head and Neck with contrast in axial plane showing multifocal infarcts likely represent complications of fungal basilar meningitis secondary to the left sphenoid sinus disease. Imaging also shows irregular erosive change at the anterior aspect of the sella turcica, through the planum sphenoidale, and bony defect of the sphenoid sinus.
Methods
Results
Conclusion
Intranasal use of cocaine causes vasoconstriction to elicit sinonasal tissue ischemia. With extended use, chronic mucosal inflammation can occur that can result in sinonasal osteocartilaginous necrosis and potential for infection. CIFS is infrequently diagnosed and its indolent nature with progression over weeks or months can make diagnosis and treatment difficult. The most frequent fungal species identified are the Aspergillus species, but Curvularia species have been found as well. CT and MRI scanning can be suggestive, but are not sufficiently specific or sensitive. The main forms of interventional modalities include surgical debridement and antifungal therapy to maximize survival
Disclosures
All Authors: No reported disclosures
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