Presentation
Refractory acute myeloid leukemia. One week of worsening left facial swelling, pain, and eye drainage. Proptosis on exam of the left eye and pain with eye movement.
Patient Data
Complete opacification of the left frontal, maxillary, and ethmoid sinuses.
Osseous erosion of the left lamina papyracea.
Extra-sinus extension of inflammation as evidenced by left extraconal orbital fat stranding, lacrimal sac soft tissue thickening, premaxillary fat stranding/swelling, pterygopalatine fossa infiltration, and infratemporal/retromaxillary fat stranding. Possible intracranial extension of inflammation via the left superior orbital fissure and foramen rotundum into the cavernous sinus.
Case Discussion
In an immunocompromised patient, the findings of sinusitis with bone erosion and/or extension of inflammation outside of the sinuses (such as into the orbit, pterygopalatine fossa, preantral fat, or nasolacrimal drainage apparatus) is most concerning for invasive fungal sinusitis. The differential includes an aggressive bacterial sinusitis and sinonasal myeloid sarcoma.
Intravenous amphotericin and broad spectrum antibiotics were started and the patient was taken emergently for operative biopsy and a limited debridement, followed by MRI to assess for intracranial extension. Pathology showed invasive fungal sinusitis with angioinvasion and necrosis. The hyphal structures identified in blood vessels and in tissue were aseptate, distorted, ribbon-like, and wide-branched, highly suggestive of a Mucorales fungus that causes mucormycosis (zygomycosis). The patient soon transitioned to hospice care and passed away 6 weeks later.
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