Invasive fungal sinusitis is a severe infection caused by ubiquitous fungi that affects the nasal and paranasal structures. In the acute form, it is a rapidly-progressing, intensely destructive disease. Chronic forms that present more insidiously also exist, and it is of the utmost importance to recognize them as prompt diagnosis is associated with a more favorable prognosis. Chronic invasive fungal sinusitis (CIFS) typically presents with symptoms of more common diseases such as sinusitis or nasal obstruction. We present a case of CIFS with the unusual presentation of post-dental procedure pain that progressed to multiple cranial nerve palsies.

We report a case of an 85-year-old immunocompetent woman who presented with a two-month history of facial pain. The patient initially reported severe pain immediately following a dental procedure two months prior, which persisted despite antibiotic therapy. In the last two weeks the patient developed headache, multiple cranial nerve palsies, and painless, blurry vision affecting the left eye. Work-up was initiated to rule out giant cell arteritis, but revealed a soft tissue mass within the pterygopalatine fossa extending into the left orbit concerning for a neoplastic process. Biopsy and histopathologic examination revealed a diagnosis of CIFS due to infection from aspergillus fumigatus. Treatment with oral posaconazole and retrobulbar amphotericin B resulted in improvement in vision and decreased mucosal thickening and inflammation.

This case is an important example of CIFS as a rare cause of ocular cranial nerve palsies and highlights the importance of considering CIFS in immunocompetent individuals when initial work-up is negative for more common pathologies. As demonstrated in the present case, immunocompetent patients may not present with classic symptoms of the disease. A high index of suspicion is necessary in such cases to avoid treatment delay.