Supplement Issue 2013 THE SOUTH AFRICAN RADIOGRAPHER peer reviewed CASE REPORT Fungal sinusitis: a case report Daleen Jacobs CT Radiographer, Drs Nisbet, Govender & Assoc. Inc., Richards Bay, South Africa Abstract This case report discusses fungal sinusitis in a healthy elderly woman. Her clinical history, radiological findings, the epidemiol- ogy and treatment options for fungal sinusitis are discussed. Keywords Aspergillosis, sphenoid sinuses, ethmoid sinuses, calcification, erosion, computed tomography. Case report requested an enhanced CT brain scan. vessels, bone, adjacent soft tissues, orbit [1] An elderly female patient consulted a This second CT scan included the maxil- and intracranial cavities . Early diagnosis neurosurgeon because of progressive lary sinuses. The findings were: opacifica- of fungal sinusitis may help prevent life- threatening complications in patients, headaches which were not responding to tion with calcification of the left sphenoid especially immunocompromised ones[2]. any form of treatment. She had a previous sinus as well as the posterior aspect of the ethmoid sinus; the left maxillary antrum The most common symptoms of fungal neck injury. The neurosurgeon requested demonstrated enhancement (Figure 4). No sinusitis are headaches, nasal obstruction a computed tomography (CT) scan of her other lesions were demonstrated. She was and purulent rhinorrhoea[3]. Patients can brain and a magnetic resonance imaging referred to an ear, nose and throat (ENT) however also present with an acute onset (MRI) scan of her cervical spine. specialist. She underwent endoscopic sur- of fever, epistaxis, sinus pain, cough, nasal In view of a possible allergy to iodine gery and a large amount of fungal debris mucosal ulcerations and crusting. Some enhanced CT scans were not possible. The was removed from the affected sinuses. It patients present with periorbital swelling, CT scan showed opacification with calci- was surrounded by an active inflamma- proptosis and mental status changes[1]. The fication in the left sphenoid sinus which tory process. Histology reports revealed a patient discussed in this case report pre- extended towards the posterior aspect of benign inflammatory ethmoid polyp and sented with common symptoms of head- the left ethmoidal sinuses (Figures 1 and colonies of aspergillus fungal organisms of aches. 2). There was erosion of the anterior wall the left ethmoid biopsy. Fungal sinusitis generally features com- of the left sphenoid sinus and of some of plete or partial opacification of the sinus. the adjacent ethmoid air cells (Figure 3). Discussion It can include areas of bone erosion as It was suggested that the patient should Fungal sinusitis is a rapidly progressive well as adjacent soft tissue infiltration. The receive ‘allergy’ preparation for contrast fungal infection of the sinuses. The infec- most common location is the maxillary enhanced imaging as the neurosurgeon tion can cross mucosa to involve blood and ethmoid sinuses, but it is found in the Figure 1: Sagittal CT image of sphenoid sinus demonstrating opacification and bone Figure 2: Coronal CT image of sphenoid sinus demonstrating opacification and bony sclerosis (arrow). erosion and sclerosis (arrow). www.sorsa.org.za 17 THE SOUTH AFRICAN RADIOGRAPHER Supplement Issue 2013 Figure 3: Axial CT image of ethmoid and sphenoid sinus demonstrating opacification Figure 4: Sagittal CT image of sphenoid sinus after administrating contrast, demon- and calcification (arrow), as well as bony sclerosis. strating enhancement (arrow). sphenoid sinuses as well[1]. Involvement immunosuppressive therapy and hemo- tions that could be responsible for the pa- of the frontal sinuses is rare[4]. chromatosis[1]. tient’s immunocompromised condition[1]. CT findings of unenhanced scans in- Studies have shown that aspergillosis of clude: complete or partial soft tissue the sinuses often develops in patients who Conclusion opacification of the affected sinus, thick- are otherwise healthy[3]. This patient had CT findings of calcifications can help in ening of nasal cavity mucosa, increased no other underlying illnesses, and would differentiation between fungal and non- [2] density of secretions suggest fungal colo- be described as a healthy individual. As- fungal sinusitis . CT scan of the sinuses nization and focal areas of bone erosion pergillosis should be confirmed with his- plays a huge role in the diagnosis of fungal of the sinus walls[1]. Calcifications are tology and not only by the CT scan as it sinusitis. Even though fungal sinusitis is almost always seen in the sinuses of pa- could be misdiagnosed as a neoplasm[2]. usually diagnosed in patients that are im- tients who had a CT scan[3]. These calcifi- Even though the CT appearances of fun- munocompromised it is also seen in oth- cations are not always observed on plain gal sinusitis are not pathognomonic, they erwise healthy patients, like the patient in x-rays[3]. Calcifications in the sinuses of are adequately characteristic to suggest this case report. If treated soon and radi- patients with fungal sinus infection can be the likelihood of the disease[4]. The most cally, the patient’s prognosis is fair. as high as 77% compared to only 3% of common organisms that cause fungal si- patients with non-fungal sinusitis. The cal- nusitis are mucorales and genus/species References cifications usually have irregular margins Aspergillus fumigates[1]. 1. Harnsberger HR, Davidson HC, Wig- with fungal sinusitis and are usually situ- The surgical features include necrotic gins 111 RH, MacDonald AJ, Hudgins ated in the centre of the sinus. Linear and tissue with discoloration due to the pres- PA, Glastonbury CM, Michel MA, nodular shaped calcifications were found ence of fungus[1]. Microscopic features Cure JK, Swartz J, Branstetter 1V B. Diagnostic imaging – head and neck. in both fungal and non-fungal sinusitis, are: fungal hyphae that invade the muco- AMIRSYS, 1995. whereas fine punctate calcifications were sa, submucosa and blood vessels, promi- 2. Yoon JH, Na DG, Sik Byun H, Koh YH, only found in fungal sinusitis[2]. Punctate nent tissue necrosis. Mucormycosis and Chung SK, Dong H. 1999. Calcification calcifications were demonstrated on this aspergillosis often invade the arteries and in chronic maxillary sinusitis: compari- patient’s CT scan. Enhanced CT scans adjacent soft tissues causing associated in- son of CT findings with histopathologic might demonstrate enhancement of the flammatory infiltration[1]. results. A Journal of Neuroradiology; peri-antral soft tissues and adjacent mus- Since fungal sinusitis is a rapidly pro- 1999, 20(April): 571-574. culature[1]. gressive disease it can be fatal unless the 3. Kwon J, Park KH, Park SI, Jin SY. Fungal sinusitis is usually diagnosed in suitable surgical-medical therapy is in- Aspergillosis of the paranasal sinuses unhealthy individuals. The saprophytic stituted. The prognosis for a patient with – diagnostic significance of computed tomography. Yonsei Medical Journal, only sinus involvement is fair, with intrac- fungi become invasive in patients with a 1989, 30(3): 294-297. mixture of predisposing conditions. The ranial and orbital involvement being the 4. Dahniya MH, Makkar R, Grexa E, most feared complication. With intracra- predisposing conditions include: diabetes Cherian J, Al-Marzouk N, Mattar M, [1] mellitus, diabetic ketoacidosis, leukaemia nial involvement the prognosis is poor . Saghir E, Fathi Al-Samman T. Appear- and bone marrow transplantation, severe The treatment consists of radical debri- ances of paranasal fungal sinusitis on malnutrition, malignancy-related neutro- dement (until histopathologically normal computed tomography. BJR; 1998, penia, end-stage renal disease, prolonged tissue is reached), antifungal therapy and 71(March): 340-344. corticosteroid or antibiotic use, chronic the treatment of any underlying condi- 18 www.sorsa.org.za.