Fungal Sphenoiditis in a Patient With ANCA-associated Vasculitis

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Abstract

Fungal sinusitis comprises a heterogeneous group of diseases differing in etiology, clinical presentation, and pathogenesis. One such form is a mycetoma, a noninvasive form characterized by the accumulation of fungal hyphae and debris within a sinus cavity, without invasion of the mucosa. Isolated sphenoid sinus mycetoma is relatively rare, and its pathophysiology remains incompletely understood. The patient’s immune status plays a critical role in the pathogenesis of fungal sinusitis, as immunosuppression is a major risk factor for the transformation of noninvasive mycetoma into an invasive form, potentially resulting in severe complications. Therefore, immune status assessment in patients with noninvasive fungal sinusitis, particularly in the presence of comorbidities and immunosuppressive therapy, is essential for determining optimal treatment strategies. This article presents a clinical case of fungal sphenoiditis in a female patient with granulomatosis with polyangiitis (ANCA-associated vasculitis) undergoing immunosuppressive therapy. The case is notable for the combination of noninvasive fungal sphenoiditis with a high risk of invasive disease due to immunosuppression. Given the elevated risk, the patient underwent endoscopic sphenoethmoidectomy followed by systemic antifungal therapy. This case highlights the importance of early surgical intervention and appropriate systemic antifungal treatment in preventing infection progression and complications in patients with noninvasive fungal sinusitis, especially in the context of immunosuppression.

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About the authors

Maria A. Shumikhina

City Clinical Hospital No. 52

Author for correspondence.
Email: masha_myxa@mail.ru
ORCID iD: 0009-0001-1557-0220

MD

Russian Federation, Moscow

Tatyana A. Shirokikh

City Clinical Hospital No. 52

Email: tshirokih83@yandex.ru
ORCID iD: 0009-0000-1360-3992

MD

Russian Federation, Moscow

Pavel V. Azarov

City Clinical Hospital No. 52

Email: azarovp@mail.ru
ORCID iD: 0009-0004-7408-7847

MD

Russian Federation, Moscow

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Supplementary files

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2. Fig. 1. Temporal changes in inflammatory markers (C-reactive protein, procalcitonin).

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3. Fig. 2. Multislice computed tomography of the paranasal sinuses (2023), sagittal and coronal views. A hyperdense lesion with a solid component (fungal ball) and an area of calcification (arrow) is observed in the right sphenoid sinus, which is characteristic of a mycetoma. No signs of bony destruction are detected.

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4. Fig. 3. Intraoperative endoscopic view. Endoscopic transnasal sphenoethmoidectomy was performed on the right side. A fungal ball occupying the lower third of the right sphenoid sinus was visualized.

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5. Fig. 4. Intraoperative endoscopic view after removal of the fungal ball. The sinus was irrigated with an antiseptic solution and 0.9% sodium chloride. No residual fungal material was detected on inspection with 30° and 70° endoscopes; the mucosa appeared edematous.

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6. Fig. 5. Multislice computed tomography of the paranasal sinuses (2024), coronal and sagittal views. A wide communication between the right sphenoid sinus and the ethmoid air cells remains along the anterior wall, up to 7 mm. No mucosal thickening or sinus contents are observed. No bony destruction is noted.

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7. Fig. 6. Endoscopic image (2024), 0° endoscope. No sinus content is observed in the right sphenoid sinus. The mucosa appears pale pink, smooth, and glistening. The sphenoid sinus ostium remains widely patent.

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8. Fig. 1. Temporal changes in inflammatory markers (C-reactive protein, procalcitonin).

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