Bilateral cellulitis caused by invasive aspergillosis associ
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A 49-year-old woman presented with a 3-month history of painful proptosis and periorbital swelling of bilateral eyes, accompanying with reduced vision and diplopia. She had been treated with antiviral medication and corticosteroids for 5 days in another hospital as the initial diagnosis was herpes virus infection, but her symptoms deteriorated. The vision at first visit was 20/25 OD and 20/30 OS. The axial and sagittal T1 contrast-enhanced magnetic resonance imaging (MRI) showed bilateral orbital lesions spreading to the cavernous sinus. She was therefore diagnosed as bilateral orbital cellulitis complicated with cavernous sinus thrombosis. Thereafter, she was given antibiotic therapy for 1?month and he
r symptoms had been improved but not healed.

On follow-up examination, best-corrected visual acuities remained as 20/25 OD and 20/30 OS. Intraocular pressures were 21?mmHg OD and 19.3?mmHg OS. Ophthalmologic examination revealed bilateral exophthalmos, bulbar conjunctival edema, and conjunctival congestion. The ocular alignment showed a limitation on the elevation and abduction of both eyes. Both pupils were round, but there was an afferent pupillary defect in the left eye. Choroidal folds observed in the right eye, and optic disc swelling with lamellar hemorrhage around optic disc was found in the left eye. MRI demonstrated orbital masses behind both globes. The only finding was that the eosinophil count was slightly above normal range. Lateral orbitotomy was next performed on the patient’s right eye. A hard mass sized 1.5 × 1.5 × 2?cm was excised with accompanying amounts of pus liquid and black necrotic tissue. Histopathological examinations diagnosed orbital granulomatosis with invasive aspergillosis infection. The patient eventually received 3-week anti-fungal therapy, itraconazole 200?mg twice a day by oral administration. Her symptoms gradually resolved. At the 8-month follow-up, the patient’s vision got improved to 20/20 OD and 20/20 OS, findings from the ophthalmic examination were unremarkable. MRI scan demonstrated that both orbital lesions regressed. She so far remained clinically stable for 3?years.

This is an unusual case about bilateral orbital abscesses with invasive fungal infection. Fungal infection of the orbit should be considered when the patient does not respond to a combination of anti-inflammatory and antibiotic therapies, even in some cases without any risk factors.