Allergic fungal sinusitis masquerading as cavernous sinus th
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A 59-year-old male, a farmer by profession, was evaluated in the emergency room with the sub-acute onset of headache and ptosis of the right upper eyelid of 3 weeks duration. He initially presented with continuous headaches in the frontal area for which he was prescribed Bactrim™. His symptoms continued to worsen with complete ptosis and he was admitted for further evaluation. He denied any pain, redness, and visual disturbance in both eyes. His past medical history was significant for systemic hypertension, which was adequately controlled. On examination, his visual acuity was 20/20 and intraocular pressures were 15 mm Hg in both eyes. Color plates were full-on Ishihara color plates, and there was no proptosis on Hertel’s exophthalmometer.

Pupils were 2 and 3.5 mm in right and left eye, respectively, with no apparent difference in anisocoria in darkness and light. There was complete ptosis of the right upper eyelid, and the right eye was completely frozen in primary gaze with full extraocular movements in the left eye. Corneal sensation was reduced on the right side along with sensation in the distribution of the V1 facial area. A diagnosis of right posterior cavernous sinus syndrome was made, and the patient was subjected to imaging. CT scan revealed complete opacification of sphenoid sinus with bony erosion. MRI of the brain revealed an expansile sphenoid sinus mass (with fluid characteristics on restricted diffusion) indicative of a pyo-mucocele. Complete blood counts were within normal limits and the erythrocyte sedimentation rate was 95 mm/hour. Immunological work-up including serum anti-nuclear antibody, anti-cytoplasmic antibody and HIV were negative. Blood cultures were negative for bacteremia and fungemia. The patient was started on intravenous vancomycin, fluconazole, and Decadron was added after 48 hours. Five days after initiating treatment, no response was noted.

He was taken to the operating room, and an endoscopic exploration of sphenoid sinus was performed through sphenoethmoid recess. There was mucopurulent material drained through sphenoid ostium, and clumps of extra mucosal ‘peanut buttery’ visco-elastic material (allergic mucin) were found in sphenoid sinus intra-operatively. One month postoperatively, the patient’s visual acuity was 20/20, and extraocular movements revealed a minimal right abduction deficit.

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