Sino-orbital aspergillosis in acquired immunodeficiency syndrome

Objective: To describe the clinical features, causes, imaging characteristi cs, treatment, and outcome of patients with the acquired immunodeficiency s yndrome (AIDS) and sino-orbital aspergillosis. Design: Records of 5 patients were reviewed. Results of imaging and histopa thologic examinations and clinical courses of the patients were studied. Results: There were 3 women and 2 men (mean age, 34.0 years). All had recei ved a diagnosis of AIDS, and mean CD4(+) cell count was 0.014 x 10(9)/L (14 cells/mm(3)). Computed tomographic scanning exhibited heterogeneous, enhan cing sino-orbital soft tissue lesions with bony erosion, and magnetic reson ance imaging disclosed soft tissue masses hypointense on T-1- and T-2-weigh ted images. The infection involved 1 or more paranasal sinuses, with extens ion into the right orbit in 3 patients and into the left orbit in 2. Patien ts were treated with aggressive surgical debridement and intravenous antifu ngal agents. In addition, local irrigation of amphotericin B was performed in 3 patients. Aspergillus fumigatus was found to be the cause in all 5 pat ients. Intracranial extension developed in 4 patients, and all subsequently died. The 2 longest surviving patients were the only ones being treated wi th protease inhibitors. Three patients had a history of frequent marijuana smoking. Conclusions: Sino-orbital aspergillosis is a progressive, relentless, and u sually fatal opportunistic infection of advanced AIDS. Patients are first s een with longstanding headache and proptosis with minimal external inflamma tory signs. Marijuana smoking may increase the risk for development of sino -orbital aspergillosis in these patients. Aggressive surgical and medical t reatment, combined with newer combination therapies using protease inhibito rs, may improve the longevity of these patients.