J Korean Ophthalmol Soc.  2017 Jun;58(6):718-724. 10.3341/jkos.2017.58.6.718.

Treatment of Rhino-Orbito-Cerebral Aspergillosis with Combination of Amphotericin, Posaconazole and Amphotericin Irrigation: A Case Report

• Kim SY
• Ko SJ
• Choi KH
• Kim SD

• KMID: 2382682
• DOI: http://doi.org/10.3341/jkos.2017.58.6.718

Abstract

PURPOSE
To report a case of rhino-orbito-cerebral aspergillosis successfully treated with a combination of amphotericin B, posaconazole and amphotericin B irrigation.
CASE SUMMARY
A 59-year-old male with hypertension, diabetes mellitus and hyperlipidemia was admitted to our neurology department for left facial paresthesia, pain and consulted to ophthalmology for left eyeball pain. His visual acuity was no light perception in the left eye, and fundus examination showed papilledema and a cherry-red spot. Left exophthalmos and complete ptosis with ophthalmoplegia were also observed. Orbital computed tomography revealed left maxillary and ethmoid sinusitis, and nasal endoscopic examination revealed a black eschar adjacent to the middle turbinate. Subsequent biopsy suggested mucormycosis. The patient was immediately treated with a combination of amphotericin B and posaconazole. In addition, left endoscopic sinus surgery was performed and aspergillosis was histopathologically confirmed. The patient underwent amphotericin B irrigation for 5 days after canula insertion up to orbital apex. The patient survived for 18 months and is still alive.
CONCLUSIONS
A combination of amphotericin B, posaconazole and amphotericin B irrigation using the canula through the orbital apex may be helpful in treating patients with rhino-orbito-cerebral aspergillosis who refuse orbital exenteration.

Keyword

Amphotericin B; Amphotericin B irrigation; Posaconazole; Rhino-orbito-cerebral aspergillosis

MeSH Terms

Amphotericin B*
Aspergillosis*
Biopsy
Diabetes Mellitus
Ethmoid Sinus
Ethmoid Sinusitis
Exophthalmos
Humans
Hyperlipidemias
Hypertension
Male
Middle Aged
Mucormycosis
Neurology
Ophthalmology
Ophthalmoplegia
Orbit
Papilledema
Paresthesia
Turbinates
Visual Acuity
Amphotericin B

Figure

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  Figure 1 Photographs of the pre-operative five cardinal positions. Extraocular muscle motion was totally limited on left eye. Also complete ptosis of left upper eyelid was noted.

• 

  Figure 2 Fundus photograph and fluorescein angiography (FAG) of left eye. (A) It showed optic disc swelling (red arrow) and cherry-red spot (blue arrow). (B) Retinal vessels were not visualized at FAG image about 100 seconds after dye injection. (C) Retinal vessels were seen at FAG image about 3 minutes after dye injection.

• 

  Figure 3 Computed tomography image and magnetic resonance T2 weighted image of orbit. (A) Soft tissue thickening with increased fat attenuation was seen at left conal space and septal area (red arrow). (B) Diffused T2 high signal intensity at left preseptal area (yellow arrow), ethmoid and maxillary sinus, retromaxillary fossa, masticator space and temporalis muscle were noted.

• 

  Figure 4 Nasal endoscopic photograph of the left nasal cavity and histopathological finding of postoperative specimen. (A) On the endoscopic examination, black-colored eschar (red arrow) and yellowish discharge (purple arrow) were observed near the middle turbinate. (B) There was septated hyphae with acute angle branching, confirmed as aspergillosis (Gomori methenamine silver [GMS] stain, ×400).

• 

  Figure 5 Photograph of the patient after operation. A canula (8 French feeding tube) was inserted up to orbital apex and fixed at 4 areas (nose, forehead, eyebrow, upper eyebrow). Amphotericin B was irrigated through the canula.

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