Invasive aspergillosis of the orbit and cavernous sinus in a patient with Aids

Lambertucci, José Roberto; Fonseca, Paloma; Linares, Daniela Barreto

doi:10.1590/S0037-86822009000600025

IMAGES IN INFECTIOUS DISEASES

Graduation Course in Health Science: Infectology and Tropical Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. Department of Surgery, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil

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A 38-year-old man, who had been HIV seropositive for 16 years and had a CD4+ cell count of 39 cells/µL, sought care because of a 1-month history of decrease in visual acuity, periorbital swelling, proptosis of the left eye and fever. He had a history of chronic sinusitis for the last 12 months which was repeatedly treated with oral antibiotics (amoxicillin/clavulanate and azytromycin) without significant improvement. Previous related-AIDS diseases included neurotoxoplasmosis, syphilis and CMV retinitis. On clinical examination there was left axial proptosis; ocular motility was restricted in the left eye (Figure A). Orbital and sinuses computed tomography scan showed left maxillary sinus opacification, bone destruction of the orbital floor and extension to intraorbital soft tissues (Figure B). Magnetic resonance of the brain (T₂-weighted) showed a hypointense lesion involving the left orbit and invading the cavernous sinus and the left internal carotid artery (Figure C). The patient was submitted to craniotomy with a presumptive diagnosis of retroorbital bacterial or fungal abscess and during surgery the diagnosis of fungal infection was confirmed. Culture of the surgical samples grew Aspergillus fumigatus. He was treated with liposomal amphothericin B and after diagnosis received voriconazole (400mg, p.o., daily) without improvement. Exenteration of the left eye and left maxillary surgical debridement was cogitated but the procedure was discarded due to the carotid artery invasion by the fungal infection. After 45 days the patient was dismissed from hospital, attending his wish to go home, and died 10 days later.

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