Invasive Fugal Sinusitis Causing Massive Epistaxis: A Case Report

Background: Invasive fungal sinusitis (IFS) is a rare entity. An increase of IFS cases is observed as the number of immunosuppressive conditions are rising. Clinical suspicion is paramount due to the rapid and aggressive behaviour of this condition. Early surgical debridement and antifungal therapy correspond the first treatment option. Overall survival rate has been reported between 50-100%. Internal carotid artery rupture is a rare complication that may cause death; when present, the endovascular approach seems to be the best option for treatment.

Case presentation: A 64-year-old man with chronic obstructive pulmonary disease presented at emergency room complaining headache and diplopia. He has been treated with intranasal and systemic corticosteroids five months ago due to an acute exacerbation of his pulmonary disease. CT-scan showed sphenoid sinus opacification with erosion of the lateral wall, superior and inferior orbital fissure. Histopathology analysis of sinus mucosa identified microorganisms morphologically compatible with mucor. After one week of treatment with liposomal Amphotericin B the patient presented to the emergency room (ER) with massive epistaxis. Anterior and posterior nasal packing was performed and the imaging revealed a carotid-cavernous fistula. A left internal carotid artery occlusion was performed, with a consequent left hemi cerebral infraction.

Conclusions: IFS may rapidly evolve to fatal consequences. Clinical suspicion in immunosuppressed patients is of critical importance as rapid and aggressive treatment may be lifesaving when facing IFS.