Purpose of Review
This review describes the clinical presentation, predisposing factors, pathophysiology, mycology, diagnosis, and therapy of sino-orbital invasive fungal infections in immunocompetent individuals. Recent advances published in the literature were reviewed with special consideration of current diagnostic methods and treatment regimens.
Owing to the rarity of this condition literature is scarce. Majority of the studies are from tropical countries such as India where the disease is relatively more common. Treatment strategies are variable and response to medical treatment is favorable in significant number of patients.
Invasive sino-orbital fungal infection in immunocompetent hosts is a rare clinical condition. Aspergillus and Mucorales group of fungi cause infection in the presence of certain risk factors. Other species of fungi may occasionally be involved. Diagnosis requires imaging and laboratory back up. CT scan remains the primary imaging modality of choice although MRI is more sensitive in picking up orbital soft tissue inflammation. With early diagnosis and appropriate medical and surgical therapy, globe salvage and visual recovery may be achieved.
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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Tomac S, Turgut S. Orbital cellulitis and irreversible visual loss owing to acute sinusitis. Ann Ophthalmol. 2006;38:131–3.
Sivak-Callcott JA, Livesley N, Nugent RA, Rasmussen SL, Saeed P, Rootman J. Localised invasive sino-orbital aspergillosis: characteristic features. Br J Ophthalmol. 2004;88:681–7.
•• Adulkar NG, Radhakrishnan S, Vidhya N, Kim U. Invasive sino-orbital fungal infections in immunocompetent patients: a clinic-pathological study. Eye. 2019;33:988–94 This paper from South India is the latest in the literature with account of 20 patients with sino-orbital fungal infections in immunocompetent patients along with review.
Verity DH, Rose GE. Infectious processes of the orbit. Chapter 232. In: Albert DM, Miller JW, editors. Albert Jakobiec’s Principals and practice of ophthalmology. Canada: Saunders Elseviers; 2008. p. 2962.
Chakrabarti A, Chatterjee SS, Das A, Shivaprakash MR. Invasive aspergillosis in developing countries. Med Mycol. 2011;49:S35–47.
Shamim MS, Siddiqui AA, Enam SA, Shah AA, Jooma R, Anwar S. Craniocerebral aspergillosis in immunocompetent hosts: surgical perspective. Neurol India. 2007;55:274–81.
Kameswaran M, al-Wadei A, Khurana P, Okafor BC. Rhinocerebral aspergillosis. J Laryngol Otol. 1992;106:981–5.
Dhiwakar M, Thakar A, Bahadur S. Invasive sino-orbital aspergillosis: surgical decisions and dilemmas. J Laryngol Otol. 2003;117:280–5.
Green WR, Font RL, Zimmerman LE. Aspergillosis of the orbit: report of ten cases and review of the literature. Arch Ophthalmol. 1969;82:302–13.
•• Pushker N, Meel R, Kashyap S, Bajaj M, Sen S. Invasive aspergillosis of orbit in immunocompetent patients: treatment and outcome. Ophthalmology. 2011;118:1886–91 The study reports efficacy of newer antifungal drug voriconazole along with other antifungals, in the treatment of invasive orbital aspergillosis.
• Mody KH, Ali MJ, Vemuganti GK, Nalamada S, Naik MN, Honavar SG. Orbital aspergillosis in immunocompetent patients. Br J Ophthalmol. 2014;98:1379–84 In a large series of 35 cases of orbital aspergillosis in immunocompetent patients, nearly 50% responded to medical therapy alone. The study highlights the importance of histopathology and microbiology in the diagnosis. Avoiding steroid therapy is emphasized.
Mauriello JA Jr, Yepez N, Mostafavi R, Barofsky J, Kapila R, Baredes S, et al. Invasive rhino-sino- orbital aspergillosis with precipitous visual loss. Can J Ophthalmol. 1995;30:124–30.
Marcet MM, Yang W, Albert DM, Salamat MS, Appen RE. Aspergillus infection of the orbital apex masquerading as Tolosa-Hunt syndrome. Arch Ophthalmol. 2007;125:563–6.
Yumoto E, Kitani S, Okamura H, Yanagihara N. Sino-orbital aspergillosis associated with total ophthalmoplegia. Laryngoscope. 1985;95:190–2.
Austin P, Dekker A, Kennerdell JS. Orbital aspergillosis: report of a case diagnosed by fine needle aspiration biopsy. Acta Cytol. 1983;27:166–9.
Spoor TC, Hartel WC, Harding S, Kocher G. Aspergillosis presenting as a corticosteroid-responsive optic neuropathy. J Clin Neuroophthalmol. 1982;2:103–7.
Slavin ML. Primary aspergillosis of the orbital apex. Arch Ophthalmol. 1991;109:1502–3.
Whitehurst FO, Liston TE. Orbital aspergillosis: report of a case in a child. J Pediatr Ophthalmol Strabismus. 1981;18:50–4.
Rose GE. Suspicion, speed, sufficiency and surgery: keys to management of orbital infection. Orbit. 1998;17:223–6.
Garrish MT, Podnos SD, Meyerhoff WL. Chronic progressive aspergillosis in an immunocompetent host. Otolaryngol Head Neck Surg. 1987;96:565–8.
Kuruba SL, Prabhakaran VC, Nagarajappa AH, Biligi DS. Orbital Aspergillus infection diagnosed by FNAC. Diagn Cytopathol. 2011;39:523–6.
Challa S, Uppin SG, Uppin MS, Umabala P, Vemu L. Diagnosis of filamentous fungi on tissue sections by immunohistochemistry using anti-Aspergillus antibody. Med Mycol. 2015;53:470–6.
Sugai A, Oyake M, Umeda M, Umeda Y, Fujita N. Case of orbital apex syndrome caused by invasive aspergillosis successfully treated during the diagnostic procedure by the use of voriconazole. Rinsho Shinkeigaku. 2008;48:746–9.
Das A, Bal A, Chakrabarti A, Panda N, Joshi K. Spectrum of fungal rhinosinusitis; histopathologist’s perspective. Histopathology. 2009;54:854–9.
Embong Z, Wan Hitam WH, Yean CY, Rashid NHA, Kamarudin B, Abidin SKZ, et al. Specific detection of fungal pathogens by 18S rRNA gene PCR in microbial keratitis. BMC Ophthalmol. 2008;8:7.
Salehi E, Hedayati MT, Zoll J, Rafati H, Ghasemi M, Doroudinia A, et al. Discrimination of aspergillosis, mucormycosis, fusariosis, and scedosporiosis in formalin-fixed paraffin-embedded tissue specimens by use of multiple real-time quantitative PCR assays. J Clin Microbiol. 2016;54:2798–803.
Rickerts V, Khot PD, Myerson D, Ko DL, Lambrecht E, Fredricks DN. Comparison of quantitative real time PCR with sequencing and ribosomal RNA-FISH for the identification of fungi in formalin fixed, paraffin-embedded tissue specimens. BMC Infect Dis. 2011;11:202.
• Rickerts V. Identification of fungal pathogens in formalin-fixed, paraffin embedded tissue samples by molecular methods. Fungal Biol. 2016;120:279–87 Limitations of culture and histopathology in confirming the diagnosis of invasive fungal infections can be overcome to some extent by molecular approach using paraffin-embedded tissue. The study describes this alternative approach in great details along with its limitations.
Antoine GA, Grundfast KM. Periorbital cellulitis. Int J Pediatr Otorhinolaryngol. 1987;13:273–8.
Hibbett DS, Binder M, Bischoff JF, Blackwell M, Cannon PF, Eriksson OE, et al. A higher-level phylogenetic classification of the fungi. Mycol Res. 2007;111:509–47.
• Walther G, Wagner L, Kurzai O. Updates on the taxonomy of Mucorales with an emphasis on clinically important taxa. J Fungi. 2019;5:106. https://doi.org/10.3390/jof5040106This extensive review provides the latest account of the constantly evolving taxonomy of Mucorales.
Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev. 2000;13:236–301.
Siddiqui A, Shah A, Bashir S. Craniocerebral aspergillosis of sinonasal origin in immunocompetent patients: clinical spectrum and outcome in 25 cases. Neurosurgery. 2004;55:602–13.
Dortzbach R, Segresr DR. Orbital aspergillosis. Ophthalmic Surg. 1983;14:240–4.
Gutierrez Diaz A, del Palacio HA, Larregla S, Sanz LA. Orbital phycomycosis. Ophthalmologica. 1981;182:165–70.
Fairley C, Sullivan TJ, Bartley P, Allworth T, Lewandowski R. Survival after rhino-orbital-cerebral mucormycosis in an immunocompetent patient. Ophthalmology. 2000;107:555–8.
Radner AB, Witt MD, Edwards JE Jr. Acute invasive rhinocerebral zygomycosis in an otherwise healthy patient: case report and review. Clin Infect Dis. 1995;20:163–6.
Gupta A, Immaculata X, Sharma SC, Mallick S. Invasive rhinosinusitis by Exserohilum rostratum in an immunocompetent child. BMJ Case Rep. 2014.
Pesic Z, Otasevic S, Mihailovic D, Petrovic S, Arsic-Arsenijevic V, Stojanov D, et al. Alternaria –associated fungus ball of orbit, nose and paranasal sinuses: case report of a rare clinical entity. Case Rep Mycopathol. 2015;180:99–103.
Pushker N, Chra M, Bajaj MS, Ghose S, Naik N, Kashyap S, et al. Necrotizing periorbital Fusarium infection-an emerging pathogen in immunocompetent individuals. J Inf Secur. 2002;44:236–9.
Greenberg RN, Mullane K, van Burik JA, Raad I, Abzug MJ, Anstead G, et al. Posaconazole as salvage therapy for zygomycosis. Antimicrob Agents Chemother. 2006;50:126–33.
Sun QN, Fothergill AW, MscCarthy DI, Rinaldi MG, Graybill JR. In vitro activities of posaconazole, itraconazole, amphotericin B and fluconazole against 37 clinical isolates of Zygomycetes. Antimicrob Agents Chemother. 2002;46:1581–2.
van Burik JA, Hare RS, Solomon HF, Corrado ML, Kontoyiannis DP. Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases. Clin Infect Dis. 2006;43:1376.
Conflict of Interest
Savitri Sharma and Saumya Jakati declare no conflicts of interest relevant to this manuscript.
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Sharma, S., Jakati, S. Sino-Orbital Invasive Fungal Infections in Immunocompetent Hosts. Curr Fungal Infect Rep (2020). https://doi.org/10.1007/s12281-020-00400-8
- Fungal infection