Invasive Sinu-Naso-Orbital Aspergilloma Following Dacryocystorhinostomy in an Immunocompetent Patient: A Rare Case Report and Literature Review

Background: Invasive sinu-naso-orbital aspergilloma is a rare disease with variable clinical features, but in an immunocompetent patient, it is rarely considered and often resulted in a poor prognosis due to its diagnostic and therapeutic challenges. In this article, we report a rare case of invasive sinu-naso-orbital aspergillosis with intracranial extension following dacryocystorhinostomy. To the best of our knowledge, this is the only reported case in the past 109 years. Case Description: A 61-year-old normotensive nondiabetic male was referred to us from an ophthalmologist with complaints of retro-orbital pain followed by progressive dimness of vision and later blindness on right eye after dacryocystorhinostomy. Diagnosis and Intervention: His MRI reveals an isointense lesion in the T1W and T2W images in the right maxillary, ethmoidal sinus with orbital and retro-orbital, and intracranial extension with heterogeneous contrast enhancement. A radiologist suggested a case of inflammatory pseudotumor, and initially he was treated with steroids due to a lack of clinical response; later, antifungal was given, but the patient still was nonresponsive. A right pterional craniotomy was performed on the patient to access the optic nerve and perform the biopsy. Aspergillus infection was seen by histopathology. Postoperatively, he was treated with voriconazole. Lessons: In immunocompetent individuals, invasive sino-orbital aspergillosis is uncommon. For effective care, early diagnosis is essential. Our advice is that a patient with vague symptoms or retro-orbital discomfort should encourage the doctor to investigate this diagnosis due to the diagnostic difficulties and greater mortality and morbidity rates. Abbreviations: DCR: dacryocystorhinostomy, PL: Perception of light, PR: Projection of rays