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Skull base osteitis following fungal sinusitis
1Department of Otolaryngology, Aintree Hospitals Trust, Walton, Liverpool.
Abstract:
Aspergillus sp. sinusitis is not uncommon in immunocompromised patients but is unusual in patients who are not immunocompromised. The disease may occur as a saprophytic condition, as an allergic sinusitis or as a potentially lethal invasive disease. The differentiation between non-invasive and invasive Aspergillus sp. sinusitis is crucial and this distinction is fully discussed. The treatment options are also considered. Invasive disease requires aggressive treatment with long-term antifungal agents in sufficient doses combined with wide surgical excision. We present a patient who presented with invasive Aspergillus fumigatus sinusitis and subsequently developed cranial neuropathies and skull base osteitis. She was initially treated with oral itraconazole (400 mg daily) for 18 months but due to lack of response this was changed to a new experimental oral azole (voriconazole) which was continued for a further 14 months. She has since remained well for the last five years.
Insights
Invasive Aspergillus sinusitis is rare in non-immunocompromised individuals. This case study highlights successful treatment of invasive Aspergillus fumigatus sinusitis with voriconazole after itraconazole failure.
Area of Science:
- Otolaryngology
- Infectious Diseases
- Mycology
Background:
- Aspergillus sinusitis can manifest as saprophytic, allergic, or invasive disease.
- Invasive forms are rare in non-immunocompromised patients and can be life-threatening.
- Differentiating non-invasive from invasive Aspergillus sinusitis is critical for appropriate management.
Observation:
- A non-immunocompromised patient presented with invasive Aspergillus fumigatus sinusitis.
- The patient developed complications including cranial neuropathies and skull base osteitis.
- Initial treatment with oral itraconazole (400 mg daily for 18 months) was ineffective.
Findings:
- Treatment was switched to voriconazole, an experimental oral azole, for 14 months.
- The patient achieved remission and remained well for five years post-treatment.
- This case underscores the potential for aggressive invasive Aspergillus sinusitis in non-immunocompromised individuals.
Implications:
- Aggressive treatment, including antifungals and surgery, is necessary for invasive Aspergillus sinusitis.
- Voriconazole represents a viable therapeutic option for refractory invasive Aspergillus sinusitis.
- Further research into invasive Aspergillus sinusitis in non-immunocompromised populations is warranted.