Acute Invasive Fungal Rhinosinusitis Complicated with Sudden Eye Blindness

INTRODUCTION

Acute invasive fungal rhinosinusitis may usually presented with an orbital complication and to the worse extent causing blindness and mortality. It is a rare condition that usually occurs due to damage to surrounding inner and surrounding bone tissue. Orbital apex syndrome may result from a variety of inflammatory, infectious, neoplastic, and vascular conditions that cause damage to the superior orbital fissure and to the optic canal leading to optic nerve dysfunction. Individuals with immunocompromised disease such as uncontrolled diabetes and immunosuppressive agents are susceptible to the fungal infections. Orbital apex syndrome due to mixed bacterial sphenoid sinusitis can be life-threatening if there is disease invasion through ophthalmic vessels or bone fissures, leading to intracranial involvement. Acute invasive fungal rhinosinusitis due to Fusarium species is a rare condition.

In this study, we have introduced the occurrence of sudden onset bilateral eye blindness due to the disease progression of Fusarium fungal species within the nasal cavity and paranasal sinuses.

By diagnosing the disease early and detecting the complications which may arise especially regarding the intracranial complications, we may eventually provide a useful and proper guidelines in managing such cases in the future.

CASE DESCRIPTION

A 42 years old Malay gentleman with an underlying end stage renal disease and thalassemia

major presented to us with a persistent facial tenderness at left frontal and ethmoidal region.

rigid nasoendoscope of the right nasal cavity showed crusting at nasal floor and on the left

side showed blood clot at left osteomeatal complex. At this point of time, he was treated

with acute rhinosinusitis.

Within 3 days duration,he started to complain of blurring of vision of the left eye.

Ophthalmological reviewed and suspected of bilateral eye glaucoma.

The next day, he started to complain of left facial pain and left eye blindness. Repeated ophthalmological tests showed evidence of central retinal artery occlusion of the left eye.

Urgent CT enhanced of the paranasal sinuses and orbit was ordered and there was mucosal thickening of the left sphenoid sinus with query of some bony defect. An urgent endoscopic sinus surgery was performed and noted that there was blackish crusting overlying the whole left nasal mucosa with pus discharge underneath. Left middle turbinate thinned out and medialized. Left uncinate bone was eroded, left maxillary ostium widened. Left maxillary sinus filled with blood clot and piece of soft tissue mass with blackish materials was sent for Histopathological examination.

Left anterior and posterior ethmoid sinus and left sphenoid sinus were filled with mucous discharge.

Post operative day 1, patient developed generalised tonic clonic seizures in the ward. An urgent CT brain was ordered and found a spontaneous Subarachnoid Hemorrhage with intraventricular haemorrhage probably secondary to vasculitis due to fungal infection affecting nearby arterial.

Patient eventually succumbed to death and results of HPE revealed mixed fungal Fusarium Equiseti sp and bacterial corynebacterium sp.

LEARNING POINT/ CONCLUSION

Worldwide, it is a very common presentation in an immunocompromised patient to develop complications related to fungal rhinosinusitis. The early detection and diagnosis of the disease may eventually reduced the mortality rate within these group of patients.

In the future, a better management protocol and guidelines maybe used in order to prevent a devastating and worse prognosis in cases like this.