2015, Volume 31, Number 2, Page(s) 161-162
Aspergillosis of the Maxillary Sinus in Chronic Myelomonocytic Leukaemia
Adriana HANDRA -LUCA
APHP Univ Paris Nord Sorbonne Cite GHU Avicenne, Service Anatomie Pathologique, Bobigny, France
To the Editor,
In patients with hematological disease, aspergillus
sinusitis occurs more frequently in acute forms1. To
our knowledge, a chronic myelomonocytic hematological
disease of leukaemia type occurred in one patient only, with
recurrent lung aspergillosis and mucormycosis2. Here we
report a case of maxillary aspergillus sinusitis occurring in
a patient with chronic myelomonocytic leukaemia showing
dental prosthesis displacement after repeated falls.
Our female patient aged of 89 years was hospitalized for
asthenia, repeated falls and weight loss (8 kg in 2 months).
Blood tests indicated fluctuant neutropenia (39%),
lymphopenia (12%), thrombocytopenia (88000/mm3),
anemia (hemoglobin 8.7 g/dL) and high C-reactive protein
(28 mg/L). The computed tomography scan was suggestive
of fungus sinusitis with displacement of the dental
prosthesis in the left maxillary sinus. A left meatotomy was
performed. Mycological direct and culture examination
were negative. The histological analysis of the submitted
resection specimen (analyzed entirely on microscopy)
showed necrotic tissues with Grocott positive filaments,
suggestive of Aspergillus (Figure 1A-C). The patient was
well at 6 months postoperatively. The patient's history
revealed Raynaud syndrome, advanced arthrosis, moderate
psoriasis, chronic right leg ulcer with staphylococcus
infection, persistent leg ecchymosis, left psoas abscess,
ischemic cardiopathy and myocardial infarction, arterial
hypertension, age-related macular degeneration and right
eye cataract, vesico-sigmoid fistula, appendectomy, and
generalized peritonitis. Six years previously, the patient was
diagnosed also with a chronic myelomonocytic leukaemia
(initial hemogram: 8600/mm3 leucocytes with 2000/mm3
monocytes, and myelogram: 3% blasts, 18% monocytes),
showing anemia (treated by transfusion and, 12 weeks
before the sinus infection, with epoetin beta), frequent
ecchymosis and hematomas in the context of moderate
thrombopenia. The patient's treatment also included
metoprolol, atorvastatin, nicorandil, acetylsalicylate lysine,
furosemide, allopurinol, zopiclone, and folic acid.
Click Here to Zoom
|Figure 1: A,B) The surgically resected specimen consisted of
abundant material with necrotic tissues (H&E; x25 and H&E;
x400), C) Grocott positive filaments and spores (Grocott; x200)
Here we present a case of maxillary aspergillus sinusitis
in an elderly adult patient with a history of repeated falls
and dental prothesis displacement as well as chronic
myelomonocytic leukaemia for 6 years. Disease associations
with psoriasis and Raynaud phenomenon, similar to
those shown by the present patient, may render clinical
complaints such as fever and an inflammatory syndrome
nonspecific. Interestingly, in the present case, there
were no nasal polyps as previously reported in sinonasal
aspergillosis3 but a recent history of repetitive falls with
dental prosthesis displacement. However, the pathogenesis
remains difficult to establish and is probably multifactorial
also related to neutropenia and potential treatment side
effects. Vasospasm might also have favored necrosis and
infection, similarly to the nasal septum perforation that can
occur in patients with psoriasis and Raynaud phenomenon4. The diagnosis of aspergillus sinusitis is important, as
the accumulated mucus may result in nasal obstruction,
and progress to facial deformity with osteolytic destruction,
and intracranial extension and, the surgical procedure
may be complicated by intracerebral hemorrhage5,6.
Although the case we present should be considered as an
allergic rather than an invasive form, the risk of invasion
with a fatal course could be encountered because of the
association with chronic myelomonocytic leukaemia7.
Systematic histological analysis of the resection specimen
becomes compulsory, mycological analysis may contribute
in less than 26% of cases due to heterogeneous distribution
of the agents7. In the present case, the diagnosis was
made on histological examination as the resected tissues
showed necrosis with Grocott positive filaments.
In conclusion, we report the case of aspergillus maxillary
sinusitis in a patient with chronic myelomonocytic leukaemia
associated with psoriasis and Raynaud syndrome. The
progression to major complications, although rare, as well
as that of several associated conditions and dental prosthesis
dysfunction in elderly patients with immunocompromising
hematological disorders, as found in the case we
report, warrant close follow-up.
1) Chen CY, Sheng WH, Cheng A, Chen YC, Tsay W, Tang JL, Huang
SY, Chang SC, Tien HF. Invasive fungal sinusitis in patients
with hematological malignancy: 15 years experience in a single
university hospital in Taiwan. BMC Infect Dis. 2011;11:250.
2) Itoha Y, Segawab H, Kitob K, Hodohara K, Ishigaki H, Sugihara
H, Fujiyama Y, Ogasawara K. Lipoid pneumonia with chronic
myelomonocytic leukemia. Pathol Res Pract. 2009;205:143-7.
3) Virk RS, Arora P. Chronic sinonasal aspergillosis with associated
mucormycosis. Ear Nose Throat J. 2007;86:22.
4) Willkens RF, Roth GJ, Novak A, Walike JW. Perforation of nasal
septum in rheumatic diseases. Arthritis Rheum. 1976;19:119-21.
5) Ferreiro JA, Carlson BA, Cody DT 3rd. Paranasal sinus fungus
balls. Head Neck. 1997;19:481-6.
6) Willard CC, Willard CC, Eusterman VD, Massengil PL. Allergic
fungal sinusitis: Report of 3 cases and review of the literature.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:
7) Vennewald I, Henker M, Klemm E, Seebacher C. Fungal
colonization of the paranasal sinuses. Mycoses. 1999;42:33-6.