A 47-year-old man comes to the office due to persistent fever, night sweats, and fatigue. Thorough evaluation yields a diagnosis of chronic myeloid leukemia. While undergoing treatment for his malignancy, the patient experiences headaches, scant nasal discharge, and left eye symptoms. Physical examination reveals tenderness over the paranasal sinuses and left-sided orbital swelling and cellulitis. Mild proptosis and ptosis of the left eye are also present. Biopsy of the sinus mucosa is shown in the image below: Which of the following is the most likely cause of this patient's condition?

Question

A 47-year-old man comes to the office due to persistent fever, night sweats, and fatigue.  Thorough evaluation yields a diagnosis of chronic myeloid leukemia.  While undergoing treatment for his malignancy, the patient experiences headaches, scant nasal discharge, and left eye symptoms.  Physical examination reveals tenderness over the paranasal sinuses and left-sided orbital swelling and cellulitis.  Mild proptosis and ptosis of the left eye are also present.  Biopsy of the sinus mucosa is shown in the image below:  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_380f_7089_9249_f578595bbdcb_MD0001_00 This patient's symptoms are consistent with fungal rhinosinusitis. The biopsy shows fungal hyphae branching at acute angles with septations, findings characteristic of Aspergillus fumigatus. This fungus is widely distributed in the environment and commonly grows on decaying vegetables. It is monomorphic, existing only in mold form (ie, multicellular hyphae). Aspergillus causes the following conditions: Invasive aspergillosis develops in immunosuppressed patients. The prolonged neutropenia associated with leukemia and lymphoma treatment is a strong risk factor. It most commonly affects the lung and can cause fever, pleuritic chest pain, and hemoptysis. Aspergillus has a predilection for blood vessels and can spread hematogenously, causing infection and infarcts involving the skin, paranasal sinuses, kidneys, endocardium, and brain. Diagnosis is made by light microscopy, which reveals V-shaped, narrow, septate hyphae invading the tissue. Voriconazole is used to treat invasive aspergillosis. Aspergillomas are Aspergillus fungus balls that grow in old lung cavities (eg, produced by tuberculosis or bronchiectasis). They are limited to the preexisting cavity; invasion of the surrounding lung tissue is rare in immunocompetent patients. Aspergillomas are often surgically removed. Allergic bronchopulmonary aspergillosis occurs in asthma and presents with wheezing and migratory pulmonary infiltrates. Increased serum IgE and increased titers of antibodies against Aspergillus are characteristic. Treatment is with corticosteroids. (Choices B, D, and F) Blastomyces, Coccidioides, and Histoplasma are dimorphic fungi. They grow as molds in nature but exist in yeast form in humans (Coccidioides exists in endospore form at body temperature). As a result, hyphae would not be seen in biopsy specimens. (Choice C) Candida albicans is a component of normal human mucous membrane flora. On light microscopy, it appears as an oval, budding yeast with pseudohyphae (ie, not true hyphae but rather elongated yeast cells). (Choice E) Cryptococcus neoformans, an oval, budding yeast with a thick capsule, causes meningitis and lung infections in AIDS. India ink stain of cerebrospinal fluid shows a wide, clear zone around the cell corresponding to the unstained capsule. (Choices G and H) Malassezia furfur and Microsporum canis can cause cutaneous fungal infections. They do not typically cause rhinosinusitis. (Choice I) Rhizopus and Mucor form broad, ribbon-shaped, nonseptate hyphae that branch at right or wide angles. They cause mucormycosis, which typically presents as a paranasal infection in immunocompromised patients or those with diabetes mellitus. However, Aspergillus can also cause rhinosinusitis identical in presentation to mucormycosis. The presence of narrow hyphae with septations makes invasive aspergillosis more likely. (Choice J) Sporothrix schenckii, often inoculated into the skin during outdoor activities, typically presents as papulonodular lesions that form along the draining lymphatics. Educational objective: Immunosuppressed patients are at risk for Aspergillus fumigatus infection. This fungus produces thin, septate hyphae with acute, V-shaped branching, causing invasive aspergillosis, aspergillomas, and allergic bronchopulmonary aspergillosis. __________ References: Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. (http://www.ncbi.nlm.nih.gov/pubmed/19544383)

A 47-Year-Old Man Comes to the Office Due to Persistent