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Sphenoid Aspergilloma: Diagnosed as a Malignancy: A Case Report

Gray MR, Thrasher JD, Dennis Hooper, Dumanov MJ, Cravens R,  Jones T

Purpose: This case study was undertaken to demonstrate the important aspects of the differentiation between a fungal infections of the sphenoid sinus vs a diagnosis of cancer. It is important to consider fungal disease in the differential diagnosis when treating masses in the sinuses. A 55 year old female employee was exposed to a waterdamaged office that had fungal and bacterial growth. She developed a sphenoid mass that was first diagnosed as cancer. After surgery, radiation, chemotherapy and a second biopsy she discharged fungal hyphae from the opened sphenoid sinus.

Methods: In 2005 her workplace was noted to have water intrusion and was inspected and tested for the presence of fungi and Gram negative bacteria. Wipe samples of dust were collected for culturing and identification of mold and bacteria. Biopsy specimens were tested by PCR DNA analysis for species of mold. The biopsy specimens were reviewed by a Medical Mycologist. The histology slides were stained with Giemsa. Sphenoid discharged materials were stained with fungalase.

Results: The sphenoid mass was shown to be an aspergilloma, Aspergillus terreus. Mycotoxins detected in urine were macrocyclic trichothecenes, aflatoxins and ochratoxin. The sphenoid aspergilloma completely resolved following oral and intranasal administration of antifungals. Multiple organ symptoms resulting from her exposure and chronic inflammation abated following detoxification and supportive antioxidant therapy. Clinical observations and diagnostic testing ruled out other causes, revealing chronic inflammation and an infection resulting from exposure to fungi and bacteria in the work environment.

Conclusions: Sphenoid aspergilloma can be medically treated with a combination of voriconazole and cyclosporine when they are administered intranasally. The required duration antifungal therapy can be determined by DNA PCR in combination with MRI and appropriate follow up. The findings are discussed and the rational for accepting the aspergilloma rather than a sphenoid malignancy is presented. It is imperative that fungal origins be considered in cases of suspected sinus neoplasms.