First report of paracoccidioidomycosis reactivation as a complication of immunosuppressive therapy for acute severe colitis in a caving enthusiast

Treatment for ulcerative colitis often requires the administration of immunosuppressive therapy. Shortly after rescue therapy with infliximab for acute severe colitis, a patient who was also taking corticosteroids, azathioprine and adalimumab became rapidly unwell with atypical pneumonia, which did not respond to conventional antimicrobials. Re-examining the travel history revealed a prior caving trip to Costa Rica. Dimorphic fungal serology was thus tested and a diagnosis of paracoccidioidomycosis was made. After a lengthy intensive care unit admission, the patient made a recovery after the administration of appropriate antifungal therapy and was discharged home on long-term oral antifungals.

Invasive Sino-aspergillosis in Immunocompetent Individuals: Atypical Presentations

ABSTRACT Aims To describe the demographic, clinical and radiological findings of invasive aspergillosis of the orbit and paranasal sinuses in immunocompetent individuals that presented without any nasal symptoms and to review the role of voriconazole in such cases. Materials and methods A series of 13 cases is being reported with review of literature. All these cases except one underwent complete surgical debridement of the disease at the time of biopsy. On histopathological confirmation of invasive aspergillosis, the cases with sphenoid sinus involvement were given 2.5 gm of intravenous Amphotericin B (1 mg/kg/day) followed by oral itraconazole in a dose of 10 mg/kg/day for 6 months. The cases where there were lesser chances of intracranial involvement or the cases that refused for intravenous Amphotericin B were started on voriconazole 200 mg twice a day for six to twelve months. All these cases were followed up with the help of radiology, clinical improvement in symptoms and signs and fungal serology. Results We found isolated sphenoid sinus involvement in 10 (76.92%) cases, isolated maxillary sinus involvement 2 (15.38%) cases and isolated orbital involvement 1 (7.69%). Our protocol was successful in 11 (84.61%) cases, one patient was lost to follow-up while one died due to intracranial complications during the third week of therapy. Conclusion This study showcased the atypical presentations of invasive aspergillosis in immunocompetent individuals and the high degree of suspicion required to diagnose this entity. An aggressive, effective and optimal management protocol has been suggested and the role of voriconazole has been highlighted.

Visual loss in the setting of allergic fungal sinusitis: pathophysiology and outcome

Objective:To hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression.Design:Retrospective, non-randomised case series. Out of 274 cases of allergic fungal sinusitis, four cases with sudden visual loss were enrolled into the study. The fourth case had visual loss on the contralateral side to bony erosion of the lateral wall of the sphenoid sinus.Interventions:All four cases were evaluated with fungal smear, immunoglobulin (Ig) E titres, visual evoked potentials, non-contrast computed tomography and magnetic resonance imaging of the paranasal sinuses, and fundus examination. They then underwent endoscopic sinus debridement followed by intravenous methylprednisolone.Outcome measures:Improvement in vision.Results:All four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case.Conclusion:In view of the operative, radiological and laboratory findings for case four, with the suggestion of a hyperimmune response to fungal antigens (in the form of raised IgE titre and positive fungal serology), we suggest that a local immunological reaction to fungal antigens might be responsible for the observed visual loss in cases of allergic fungal sinusitis, in addition to mechanical compression of the optic nerve.