Abstract
A 14-year-old male presented to the ophthalmology clinic with a history of asthenopia. Laboratory, radiological and histopathological studies confirmed the diagnosis of allergic fungal sinusitis resulting in lateral displacement of the medial rectus muscles. Symptoms improved and near point of convergence recovered after surgical endoscopic decompression of the ethmoidal and maxillary sinuses.
Keywords: Allergic fungal sinusitis, Asthenopia, Convergence, Paranasal sinuses
Introduction
Allergic fungal sinusitis (AFS) is a non-invasive sinusitis affecting young atopic, immunocompetent patients living in warm, humid climates.1 The disease is characterized by recurrent sinusitis, eosinophilia, and raised serum immunoglobulin E levels. Patients with AFS typically present to the otolaryngologist with symptoms of sinusitis, and nasal obstruction. However, ocular symptoms may appear at a later stage of the disease.
In this report we describe a case of advanced AFS presenting with asthenopia as the initial complaint.
Case report
A 14-year-old Saudi male presented to the ophthalmology clinic with a 4 month history of eye strain on reading. His symptoms progressively worsened and he had to abandon performing any near visual task. Review of systems revealed a 2 year history of intermittent runny nose, sneezing and frontal headache for which he never sought medical advice.
Hypertelorism and mouth breathing were evident on gross examination. His unaided monocular near vision was N5 in the right and left eyes at 10 cm, yet he immediately complained of moving print, diplopia and eye strain on attempting binocular near vision assessment. The unaided distance visual acuity was 6/6 for both eyes with no diplopia. Orthoptic examination revealed 15 prism diopters of exotropia for near but he was otherwise orthophoric for distance.
There was a limitation of adduction in both eyes and his near point of convergence had receded to 18 cm (Fig. 1). All other aspects of ocular motility were full and examination of anterior and posterior segments was otherwise unremarkable.
Figure 1.
Limited adduction of both eyes with recession of near point of convergence at presentation.
Computed tomography scan of the paranasal sinuses showed heterogeneous, high attenuation opacities completely filling all paranasal sinuses and the nasal cavity. The lesion caused the expansion of the maxillary and ethmoidal sinuses and lateral displacement of both medial rectus muscles. There was no radiological evidence of intra-orbital invasion (Fig. 2).
Figure 2.
Coronal computed tomography (CT) scan showing heterogeneous opacity filling all paranasal sinuses and causing expansion of the maxillary and ethmoidal sinuses.
Laboratory investigations revealed eosinophilia (eosinophil count of 11%) with a 10-fold increase in IgE level (1174 kU/l). The patient was tentatively diagnosed with allergic fungal sinusitis and referred to the otolaryngology service for specialized treatment.
Functional endoscopic sinus surgery with an extensive debridement of the ethmoidal and maxillary sinuses was performed. Histopathological examination of the lesion revealed inflammatory necrotic debris intermixed with copious mucinous materials. Aspergillus hyphae were evident on Gomori-Grocott methenamine silver (GMS) stain.
The patient symptoms of asthenopia gradually improved over a period of 2 months with full recovery of the medial rectus function and a normal near point of convergence to 10 cm (Fig. 3).
Figure 3.
Recovered medial recti function and near point of convergence two months post surgery.
Discussion
Allergic fungal sinusitis is the most common form of fungal sinusitis which accounts for about 8% of all sinusitis cases requiring surgical intervention.
The disease possibly represents an IgE and IgG mediated hypersensitivity reaction to Aspergillus or dematiaceous fungal infection.2,3 Delay in diagnosing AFS is not uncommon as the disease has a slow, sustained clinical course with a wide range of differential diagnoses.4
Typically, patients present to ENT specialists with symptoms of chronic sinusitis; however, ophthalmologists could be involved at a later stage of the disease in cases of secondary ophthalmic manifestations. Proptosis, epiphora and telecanthus are the most commonly reported ophthalmic complaints. Additionally, serious complications such as visual loss and ophthalmoplegia have also been reported.5–7
Our patient managed to cope with the symptoms of chronic sinusitis for quite some time prior to presenting to the ophthalmology clinic with asthenopia. His AFS was advanced enough to cause lateral displacement of the medial rectus muscles with subsequent impairment of convergence. This is a rather unusual presentation of AFS for which we found no previous references in medical literature.
Source of support
None.
Conflict of interest
None.
Propriety interest
None.
Acknowledgements
The authors thank Dr. Deepak Maniyath Keezhanthi, MD for his assistance in management of the case, Dr. Nidal Dabbour, MD for his help in histopatholoigcal diagnosis, and all the nursing staff in out-patient department and operating room in Imam Abdulrahman Bin Faisal Hospital, Dammam, Saudi Arabia. The authors report no propriety interests in the materials presented in this article. The authors state no grants or financial support were used in writing this article.
Footnotes
Peer review under responsibility of King Saud University.
References
- 1.Klapper S.R., Patrinely J.R. Orbital involvement in allergic fungal sinusitis. Ophthal Plast Reconstr Surg. 2001;17:149–151. doi: 10.1097/00002341-200103000-00016. [DOI] [PubMed] [Google Scholar]
- 2.Bent J.P., 3rd, Kuhn F.A. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994;111:580–588. doi: 10.1177/019459989411100508. [DOI] [PubMed] [Google Scholar]
- 3.Schubert M.S., Goetz D.W. Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis. J Allergy Clin Immunol. 1998;102:387–394. doi: 10.1016/s0091-6749(98)70125-3. [DOI] [PubMed] [Google Scholar]
- 4.Kuhn F.A., Swain R., Jr. Allergic fungal sinusitis: diagnosis and treatment. Curr Opin Otolaryngol Head Neck Surg. 2003;11:1–5. doi: 10.1097/00020840-200302000-00001. [DOI] [PubMed] [Google Scholar]
- 5.Chang W.J., Tse D.T., Bressler K.L. Diagnosis and management of allergic fungal sinusitis with orbital involvement. Ophthal Plast Reconstr Surg. 2000;16:72–74. doi: 10.1097/00002341-200001000-00016. [DOI] [PubMed] [Google Scholar]
- 6.Marple B.F. Allergic fungal rhinosinusitis: current theories and management strategies. Laryngoscope. 2001;111:1006–1019. doi: 10.1097/00005537-200106000-00015. [DOI] [PubMed] [Google Scholar]
- 7.Carter K.D., Graham S.M., Carpenter K.M. Ophthalmic manifestations of allergic fungal sinusitis. Am J Ophthalmol. 1999;127:189–195. doi: 10.1016/s0002-9394(98)00371-7. [DOI] [PubMed] [Google Scholar]