Case Presentation: A 19-year-old Hispanic man presented with 3 weeks of worsening right frontal headache associated with blurred vision and protrusion of right eye. Exam was significant for right eye proptosis with restricted upward gaze. Head CT revealed extensive sinus inflammation with erosion of the right maxillary and sphenoid sinuses and extension into the right orbit causing proptosis. Past medical history was significant for asthma and eczema as a child. The patient did note that he had been taking loratadine recently for nasal congestion but denied any other prior history of allergic rhinitis or sinus infections. Lab evaluation was significant for an elevated IgE of 1892 U/mL but remainder of labs were unremarkable including a normal white blood cell count and differential.
ENT and ophthalmology were consulted and he underwent endoscopic sinus surgery revealing deviation of the septum with inflammatory debris filling all right paranasal sinuses. Pathologic evaluation of specimens showed mucin with abundant eosinophils and Charcot-Leyden crystals consistent with allergic mucin. Staining showed evidence of fungal organisms but bone specimens showed no evidence of any bony invasion. Clinical presentation and findings were consistent with a diagnosis of allergic fungal sinusitis (AFS). His symptoms improved post-operatively, and he was discharged with an oral steroid taper. Six months later, he required additional surgical intervention for recurrent disease.
Discussion: Allergic fungal sinusitis (AFS) develops as a result of immune mediated hypersensitivity to fungal antigens. It is more prevalent in warm, humid environments, particularly in the southern regions of the US. Atopic, immunocompetent young adults are most affected. The most common presenting symptoms include: nasal congestion, thick, dark, “peanut-butter-like” nasal discharge, anosmia, and headache. In children, proptosis and facial dysmorphia are more common at presentation, while nasal polyposis is more common in adults.
This presentation is related to the inflammatory response to fungal elements, rather than infection. Often, serum IgE levels are greater than 1000 U/mL. Pathology often shows abundant eosinophils, Charcot-Leyden crystals, and fungal hyphae, as seen in our patient. Management of AFS is both surgical and medical, consisting of endoscopic sinus surgery followed by systemic and/or topical steroids. Other potential treatments include leukotriene modulators and allergen desensitization, but evidence is limited. Antifungals are not routinely needed for treatment but could be considered in refractory cases. In children, AFS tends to be more aggressive and less responsive to treatment, resulting in higher recurrence rates.
Conclusions: This case reviews a severe presentation of allergic fungal sinusitis with the intent to increase awareness of AFS among hospitalists. Early recognition and diagnosis can prevent unnecessary exposure to antimicrobial medications and shorten hospital stays.