Orbital aspergillosis: a case report
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Orbital aspergillosis is a rare sight- and life-threatening fungal infection affecting immunocompromised or otherwise healthy patients. It is often misdiagnosed due to its unspecific clinical and radiologic appearance. Therapeutic delay can have dramatic consequences. However, progress in microbiological diagnostic techniques and therapeutic experience from case series help improve the management of this disease.

A 78-year-old immunocompetent woman presented at an eye clinic for subacute swelling, reddening, and ptosis of her left upper eyelid. Based on radiologic and histologic considerations, she was treated for idiopathic orbital inflammation, but her condition worsened. After a second biopsy of the orbital mass, aspergillosis was diagnosed. Her condition improved promptly after the initiation of an oral voriconazole treatment. In the following two weeks under oral prednisolone (80 mg tapered by 10 mg every 4 days), the patient’s condition did not improve. An extended, deeper biopsy specimen was taken, revealing a granulocytic reaction (eosinophilic and neutrophilic) and fungal hyphae with ramification at a 45° angle, characteristic of Aspergillus spp., pointing to the diagnosis of orbital aspergillosis. The patient was transferred to an infectious disease department for further evaluation and therapy. Further blood work continued to show no sign of systemic infection. Given these results, oral therapy with voriconazole was initiated. In the following days, the plasma trough concentrations of voriconazole were within the target range of 1.0–5.5 mg/L.

Using PCR on paraffin-fixed biopsy tissue, A. fumigatus was identified in both biopsy specimens. Using the same test, mutations that are typically associated with azole-resistance were ruled out. In the following 2 years, under sustained oral voriconazole treatment, the patient showed a clear clinical and radiologic improvement, and (1–3)-?-D-glucan turned negative after 3 months. The best-corrected visual acuity (BCVA) for the left eye recovered to 0.7 (Snellen: 20/25). Since the therapy was well tolerated and the drug concentration stayed within the therapeutic range, the voriconazole treatment was continued to minimize the risk of relapse.

In the case described here, oral antifungal treatment was sufficient for the therapy of invasive orbital aspergillosis. Performing fungal PCR on orbital tissue can accelerate the diagnostic process and should be performed in ambiguous cases of slowly growing orbital mass. Finally, interdisciplinary management is the key to optimal treatment of orbital tumors and infections.