Aspergillus infection of the paranasal sinuses is an unusual phenomenon but is the commonest fungal infection of these structures. A 67 year-old man was admitted with six months' lethargy, vomiting, and weight loss. Past history included sinusitis. On examination he was well but dehydrated. BP 100/60. No other abnormal findings. Routine blood results were normal.
A provisional diagnosis of upper GI malignancy was made but gastroscopy was normal. The thyroid function tests returned the next day, TSH 0.22, fT4 5.7 and thyroxine was started by an SHO. Later that day the patient collapsed, BP 70/40, pulse 50. The TFT were noted by a registrar who administered IV hydrocortisone. A random serum cortisol returned at 80nmol/l. Over the next 24 hours all his symptoms resolved.
Subsequent results: Testosterone <0.7nmol/l, FSH 1.0mIU/ml LH<0.5mIU/ml, RandomGH 2.1mu/l, Prolactin 246mu/l. MRI showed a mass in the sphenoid sinus with rim enhancement consistent with tumour or abscess. There was no bony erosion and the pituitary gland itself looked normal.
After 2days of hydrocortisone he complained of polyuria >5 litres/day. Serum osmolality 343mosm/kg, urinary osmolality 262mosmol/kg. ddAVP led to rapid resolution of symptoms.
Endoscopic exploration revealed a sphenoid sinus filled with friable brown material that cleared piecemeal on washing. Histology showed the mass to be an aspergilloma with no evidence of tumour. T cell subsets were normal. He required no anti-fungal treatment and was discharged well on ddAVP, thyroxine and hydrocortisone. We postulate that the aspergilloma affected pituitary function by contiguity (inflammatory or vasculitic process) since there has been no evidence of direct invasion into the gland itself.
Follow up MRI showed gradual reduction in size of the aspergilloma. He is currently undergoing reassessment of pituitary function.
This case illustrates a rare cause of hypopituitarism by an aspergilloma in the sphenoid sinus in an immunocompetent individual.
03 - 04 Dec 2001
Society for Endocrinology