Orbital Apex Syndrome Due to Aspergillus flavus Infection in Immunocompetent Patients: A Report of Two Cases

Aspergillus species are fungi that are commonly found in soil and decaying vegetation and have the potential to cause an orbital apex syndrome that is marked by ophthalmoplegia or vision loss. We report the clinical and investigational findings and outcomes of two patients with orbital apex syndrome. The first patient was a 26-year-old female, premorbidly healthy, who presented with a gradually increasing proptosis of the left eye with a reduction in vision. An MRI revealed findings consistent with proptosis, pansinusitis with a soft tissue opacity involving the left orbital apex with optic nerve compression, extending to the cavernous sinus with an associated temporal meningeal enhancement. Following functional endoscopic sinus surgery (FESS), Aspergillus flavus was grown in culture, and oral voriconazole was initiated. The second patient was a 53-year-old male who presented with bilateral reduction of vision and ptosis, proptosis with total ophthalmoplegia (third, fourth, and sixth nerve palsies) of the right eye. An MRI study revealed extensive involvement of the apex of the right orbit, the right cavernous sinus, the medial aspect of the left cavernous sinus, and the pituitary gland. A FESS was done, and the histopathology specimen was suggestive of aspergillosis, and the tissue fungal polymerase chain reaction (PCR) test was positive for Aspergillus flavus. He was treated with amphotericin B and oral voriconazole with significant improvement. Physicians need to have a high index of suspicion for invasive fungal sino-orbital infections, even in immunocompetent patients. The presence of nasal congestion, recurrent sinusitis, facial pain, headache, orbital cellulitis, proptosis, or ophthalmoplegia should prompt early investigations.