Case Presentation: 23- year old Latino male with no known history presented to the ER complaining of worsening left eye pain. Patient stated that he has been cleaning manmade lakes and for one week started to have an erythematous and painful left eye associated with persistent frontal headache, and blurry vision. Patient endorsed recent diagnosis of allergic rhinosinusitis and use of intranasal corticosteroids three months prior to presentation which he used 2-3 times daily despite prescription for once daily. On exam patient had normal vital signs. His physical exam was significant for left eye proptosis and erythema without purulence. Visual acuity was 20/40 bilaterally and extraocular muscles were intact. Patient had nontender sinuses. Presenting labs were within normal limits. MRI of the orbits w/wo contrast showed non-enhancing, hypointense material severely distending the left ethmoid, sphenoid, frontal sinuses with deviation of the medial rectus and overlying mild dural enhancement suggesting mild meningitis. Patient was admitted for invasive rhinosinusitis versus malignancy and started on IV dexamethasone.   

Evaluation for immunocompromised status was negative including HbA1c, ANA, and HIV. Biopsy of the left nasal wall was consistent with allergic fungal sinusitis on histophathology. GMS stained scattered fungal hyphae amid the eosinophils with rare acute angle branching suggesting aspergillus species. No malignancy was identified.   Infectious disease was consulted and initiated voriconazole for presumed invasive aspergillus with a loading dose of 6mg/kg intravenous once followed by 200mg PO BID. Patient was transferred to tertiary care center for multispecialty surgical debridement. 

Discussion: Intranasal corticosteroids are widely available for treatment of common inflammatory states because of their minimal systemic side effects. Despite their relative safety, clinicians must recognize the potential for local immunosuppression and possible pathology commonly seen only in immunocompromised patients. Our patient was an immunocompetent young male who initially presented with proptosis and visual impairment.  Orbital MRI showed a mass concerning for neoplasia however his occupational history and acute overuse of intranasal steroids made infection a possible etiology.  Aspergillosis was confirmed histopathologically, therefore making it likely to be a direct consequence of intranasal corticosteroid creating local immunocompromised environment for the growth of aspergillus. Aspergillus infections in immunocompenant individuals include five common presentations none of which are invasive.  Our patient had invasive rhinosinusitis which could only be explained by local immunosuppresion. Only one other case has been reported rhinosinusitis from aspergillosis after nasal steroid use, however it occurred after chronic use; uniquely our patient had an acute infection with < 4 months use.  

Conclusions: Intranasal corticosteroids are widely available over the counter; we describe a serious and previously unreported complication of their use, and the importance of clinical reassessment for intranasal steroid requirement. This case also highlights a unique etiology for proptosis and emphasizes the significance of history taking and multidisciplinary communication.