Rapidly Progressive Orbital Apex Syndrome Due to Scedosporium apiospermum Following Endoscopic Sinus Surgery

Scedosporium apiospermum is a ubiquitous, highly resistant opportunistic fungus found in sewage and polluted waters and may infect the paranasal sinuses. Orbital Apex Syndrome may occur following trauma, surgery, or infection. An 80-year-old male with diabetes mellitus and mild dementia underwent uncomplicated, bilateral functional endoscopic sinus surgery for chronic sinusitis with polyposis. Initial pathology was reported as non-invasive bacterial and fungal species. On postoperative day 4, he had sudden right vision loss and abducens nerve palsy. Imaging noted violation of the lamina papyracea and inflammation of the optic nerve without compression. Medical therapy was begun and the patient developed sudden vision loss of the left eye. The patient then underwent emergent surgical decompression of both optic nerves. A final culture from the original surgery of S. apiospermum was made on postoperative day 10. Aggressive medical therapy was continued and the patient ultimately expired from complications of medical therapy and other underlying conditions. Trauma to the delicate bony walls of the orbit during sinus surgery in an immunocompromised patient who is unknowingly colonized with S. apiospermum can lead to the rapid spread of this highly neurotoxic organism.