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The Best in FOAM Education

  • David Rapaport, MD



62 year old female presents with 2 weeks of clear watery discharge from the left eye and painless erythema between the left eye and nose. Endorses nasal congestion bilaterally. Denies fevers/chills, headache, sinus pain, cough, shortness of breath, malaise, fatigue, nausea/vomiting, vision changes or other symptoms.

Past medical / surgical history

Renal transplant, hypertension, hyperlipidemia, diabetes, cerebrovascular accident, coronary artery disease, nasal sinus abscess (pseudomonal growth) status post incision and drainage 3 months prior, COVID-19 infection 4 weeks prior

Allergies: seasonal

Medications: many to include tacrolimus, mycophenolate, insulin

Physical Exam

Vitals: Temperature 36.5 C, HR 66, RR 18, BP 120/64, SpO2 98% on RA

General: Alert, no acute distress, nontoxic appearing

Skin: 2cm diameter, nontender, erythematous area between left eye and nose. No fluctuance or swelling noted.

Eye: extraocular movements intact, visual acuity intact, PERLLA, Normal conjunctiva

ENT: Oral mucosa moist

Cardiovascular: regular rate and rhythm. No murmur, rubs, gallops. No peripheral edema.

Respiratory: Clear to auscultation bilaterally. Equal chest rise.

GI: Soft, nontender, nondistended

Neurological: A&O x3, no focal neurologic deficits observed


Covid 19

Viral illness

Seasonal allergies



recurrent abscess

something else?

Laboratory findings

**abnormal labs similar to prior visits

Radiographic Findings

CT face and sinuses, non-contrasted


Evaluation for abscess is limited without intravenous contrast.

Significant opacity within the paranasal sinuses with osseous dehiscence of the left lamina papyracea, medial maxillary sinus walls and hard palate.

Infiltration and likely spread of infection to involve the extraconal medial left orbit, left pterygopalatine fossa and left retro antral fat.

Recommend further evaluation with MRI of the brain and sinuses with and without contrast and clinical correlation for acute invasive fungal sinusitis.

ED Clinical Course

  • Clinical condition stable, zosyn given

  • Transplant, ENT, ophthalmology consulted

  • ENT nasopharyngeal endoscopy revealed black discolored tissue, biopsy obtained in ED.

  • Patient admitted to medicine

Hospital Clinical Course

Inpatient MRI Brain and Sinuses with and without contrast


Acute invasive fungal pansinusitis involving the left medial orbital wall, pterygopalatine fossa extending to the sphenopalatine foramen and pterygomaxillary fissure, and left masticator space as described above. Questionable involvement of the left orbital apex. No evidence of intracranial extension. No intracranial abscess at this time.

Infectious disease consulted, recommended amphotericin B, vancomycin, cefepime, metronidazole pending biopsy results.

ENT planning OR for debridement

-Course to be continued



Acute sinusitis with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. All sinuses become involved, spread to contiguous structures to include the palate, orbit, and brain. Usually progresses rapidly over the course of days.

  • Fever - 44%

  • Nasal ulceration and/or necrosis - 38%

  • Periorbital or facial swelling - 34%

  • Decreased vision - 30%

  • Sinusitis - 26%

  • Ophthalmoplegia - 29%

  • Headache - 25%

Risk factors

  • Diabetes mellitus, particularly DKA

  • Glucocorticoid usage

  • Hematologic malignancies

  • Hematopoietic cell transplantation

  • Solid organ transplantation

  • Recent COVID19 infection

  • AIDS

  • IV drug use

  • Trauma / burns

  • Malnutrition

  • Iron Overload


David Rapoport, MD


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