A “Terrible” Headache in a HIV Patient

Abstract

Mucormycosis is a type of fungal infection more prevalent among immunosuppressed patients, requires prompt identification and surgical treatment, as it can is associated with local and distant spread. This case is aiming to highlight the importance of early identification of subtle symptoms in immunocompromised patients. The clinician should be aware of fungal sinusitis, consider it in the differential diagnosis, and seek for an ear, nose, and throat opinion.

Clinic—Case Presentation

A 52-year-old, HIV-positive male patient was admitted with a severe occipital headache which was not responding to simple analgesics. The HIV infection was diagnosed 10 years ago, his past medical history also included liver cirrhosis, and the patient was on HIV treatment with Darunavir, Raltegravir, Ritonavir, and Abacavir. His lymphocyte count was 400/μL, with his CD4 count being 36.8% of his total lymphocytes. The patient had a magnetic resonance imaging head, which showed unilateral isolated sphenoid sinus opacification, with a mixed homogeneity and a “salt and pepper” appearance (Figure 1). Interestingly, flexible nasendoscopy did not show any necrotic foci, and there were no cranial nerve palsies. His symptoms improved on intravenous antibiotics, antifungal treatment, and opioid analgesia, and the patient was discharged home, as he was not keen to have surgery. He then returned 6 weeks later with similar but worsening symptoms.

Figure 1.

Magnetic resonance imaging of nose and paranasal sinuses axial view showing isolated left sphenoid sinus opacification with a mixed signal (salt and pepper appearance).

The clinical picture and the imaging are suggestive of a fungal sphenoiditis. After ear, nose, and throat consultation and, in the light of symptomatic deterioration, the patient underwent a semi-urgent endoscopic sphenoidotomy after appropriate platelet transfusion. It was obvious that he had a severe fungal infection that was occupying his left sphenoid sinus (Figure 2). This was completely cleared out and histology showed mucormycosis, which fortunately was not disseminated elsewhere in his cranium. He had an uneventful recovery with immediate relief of his headache and remains on antifungal treatment. Mucormycosis and not just simple fungal infection should always be considered in HIV and other immunocompromised patients. ¹ The appropriate treatment of choice is surgery in the form of endoscopic debridement, followed by systemic antifungal treatment and close monitoring for clinical, endoscopic, and radiological recurrence.

Figure 2.

Endoscopic view of the nose during surgery, revealing fungal infection of the sphenoid sinus.