Sino-orbital aspergillosis in acquired immunodeficiency syndrome

Objective: To describe the clinical features, causes, imaging characteristics, treatment, and outcome of patients with the acquired immunodeficiency syndrome (AIDS) and sino-orbital aspergillosis. Design: Records of 5 patients were reviewed. Results of imaging and histopathologic examinations and clinical courses of the patients were studied. Results: There were 3 women and 2 men (mean age, 34.0 years). All had received a diagnosis of AIDS, and mean CD4⁺ cell count was 0.014 x 10⁹/L (14 cells/mm³). Computed tomographic scanning exhibited heterogeneous, enhancing sino-orbital soft tissue lesions with bony erosion, and magnetic resonance imaging disclosed soft tissue masses hypointense on T₁- and T₂-weighted images. The infection involved 1 or more paranasal sinuses, with extension into the right orbit in 3 patients and into the left orbit in 2. Patients were treated with aggressive surgical debridement and intravenous antifungal agents. In addition, local irrigation of amphotericin B was performed in 3 patients. Aspergillus fumigatus was found to be the cause in all 5 patients. Intracranial extension developed in 4 patients, and all subsequently died. The 2 longest surviving patients were the only ones beeing treated with protease inhibitors. Three patients had a history of frequent marijuana smoking. Conclusions: Sino-orbital aspergillosis is a progressive, relentless, and usually fatal opportunistic infection of advanced AIDS. Patients are first seen with longstanding headache and proptosis with minimal external inflammatory signs. Marijuana smoking may increase the risk for development of sino-orbital aspergillosis in these patients. Aggressive surgical and medical treatment, combined with newer combination therapies using protease inhibitors, may improve the longevity of these patients.