Presentation
Evaluate for mass and retroorbital swelling. Per ordering provider, patient has a history of lymphoma and presents with several weeks of progressive left-sided exophthalmos and orbital pain.
Patient Data
There is homogeneously enhancing soft tissue along the greater and lesser wings of the left sphenoid bone. This results in effacement of the left superior orbital fissure as well as encasement of the left optic canal. There is dehiscence of the left orbital roof just ventral to the left superior orbital fissure. Furthermore, enhancing soft tissue extrudes into the extraconal space of the left orbit along the cephalad margin of the left superior rectus muscle and lateral margin of the left lateral rectus muscle.
The left cavernous sinus displays normal morphology and enhancement. However, note is made of reactive mucoperiosteal thickening throughout the left sphenoid sinus air cell. There is infiltration of the perineural fat within the left pterygopalatine fossa. This infiltrative enhancing soft tissue results in proptosis of the left globe.
The right orbit and globe is within normal limits. Dystrophic calcification is noted within the right parotid gland without associated ductal dilatation. Incidental note is made of a retained metallic foreign body adjacent to the left mandibular body.
Case Discussion
This is a case of blastomycosis affecting the orbit. Given the history of systemic lymphoma, the patient was presumed to have orbital lymphoma.
The patient underwent surgical debridement. Pathologic specimens were sent for analysis. Histopathology revealed benign fibroconnective tissue with necrotizing granulomatous inflammation, particularly in the area of the left orbital apex. Grocott's methenamine silver was positive for budding yeast forms, up to 15 micron in size. Morphology of the budding yeast forms were characteristic of Blastomycosis.
The patient was treated with amphotericin-based therapy, which was then transitioned to itraconazole. The patient did not experience recurrence following therapy.
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