2018 Research Forum

Invasive fungal sinusitis minimally evident by physical examination Presenter: Laura Celene Castro RA Principal Investigator & Faculty Sponsor: Manish Amin DO Manish Amin DO 1 , Vikram Shankar MD 2 , Phillip Aguiñiga-Navarrete RA3, Laura Castro RA 3 1 Emergency Medicine Faculty; Health Sciences Associate Clinical Professor, David Geffen School of Medicine UCLA 2 Resident Physician R2 3 Emergency Medicine Research Assistant Program INTRODUCTION We describe a case of chronic invasive fungal sinusitis (IFRS), presenting with minimal physical examination findings. Photographic signed consent was obtained from the patient, including IRB approval for this case report. PURPOSE A 35-year-old female with a history of intracranial fungal abscess with surgical resection in 2007 presented to our facility with a headache for four months. Her headache was located along frontal sinuses. Vital signs were normal. Head examination was significant for minimal left maxillary swelling with mild tenderness to palpation (Figure 1). A fibrotic scar was present from previous craniectomy. Nasal turbinates were normal appearing. Neurologic examination was non-focal. CBC and electrolytes were within normal limits. Ct of the face showed ethmoid and maxillary sinus bone destructions with extension into the right frontal lobe and surrounding fascial structures, consistent with severe fungal disease (Figure 2). Inpatient nasal endoscopy with biopsy showed fungal elements consistent with Aspergillus species. DISCUSSION The extensive and severe nature of this patient’s pathology was not appreciated by physical examination. Aspergillus species, Fusarium species, the Mucorales, and dematiaceous (brown- black) molds are among the most common causative agents of invasive fungal sinusitis1,2. The chronic course is typically greater than 12 weeks and takes an indolent form which may present with little or no systemic signs or symptomps.2,3Therefore, the emergency physician must maintain a high index of suspicion for such pathology. CONCLUSION In general, invasive rhinosinusitis is difficult to cure and survival rates are poor. Long term sinonasal complications may develop.6 Because of poor prognosis, early diagnosis and aggressive treatment is necessary. A high index of suspicion for invasive fungal infection should be maintained in patients complaining of sinus symptoms including facial pain and headache, especially in the setting of immunocompromised status.

Figure 1. Minimally evident presentation of invasive fungal infection.

Figure 2. Mass with extension into ethmoid and maxillary sinuses

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