An unusual cause of blindness.

Allergic bronchopulmonary aspergillosis (ABPA) is caused by colonisation of the lungs with Aspergillus fumigatus resulting in a hypersensitivity reaction and bronchiectasis. Allergic asper-gillus sinusitis (AAS) has similar histopathological features and yet simultaneous occurrence is rarely reported. We report a case of an aspergilloma in the paranasal sinuses causing unilateral blindness with associated AAS. The patient went on to develop ABPA resulting in a dramatic decline in lung function. Therapy consisted of oral steroids, an anti-fungal agent, bronchodilators and bronchial hygiene. A 48-yr-old female presented to her general practitioner in 2006 with sudden loss of sight in the left eye. Following an urgent computed tomography (CT) head scan she was referred to the Ear Nose and Throat surgeons (Royal Infirmary Edinburgh, Edinburgh, UK) with the radiological diagnosis of a cystic lesion in the region of the sphenoethmoid sinus (fig. 1). She underwent an endoscopic sphenoid sinus debride-ment and washout. Cellular pathology of the sinus biopsy showed an oedematous and hyalinised lamina propria, containing an infiltrate of plasma cells, eosinophils and lymphoid aggregates. Branching septate fungal hyphae consistent with Aspergillus sp. were identified. The patient was diagnosed with an aspergillus fungal ball and sinusitis. Full vision was restored completely and no further treatment was instituted. Later that year she presented with worsening exertional breathlessness and wheeze, a productive cough with mucous plugs and weight loss (body mass index 17.7 kg?m-2). She had history of severe asthma since childhood during which time she had been admitted to hospital several times, once requiring ventilation. In adulthood she reported reasonable asthma control apart from an admission for pneumonia in 1999 and had never been diagnosed with ABPA. On this occasion her sputum grew Aspergillus fumigatus (5,000 cfu?mL-1) for the first time and a CT scan of the thorax revealed central bronchiectasis, tubular and varicose, involving all lobes with ground-glass attenuation and coarse thickened linear markings (fig. 2). She was positive for aspergillus precipitins, her total immunoglobulin (Ig)E was .5,000 Ku?L-1 , Aspergillus IgE was 52.80 Ku?L-1 and her eosinophil count was 4.13 10 9 ?L-1. Her spirometry revealed a forced expiratory volume in 1 s (FEV1)/vital capacity (VC) ratio of 48% predicted with minimal reversibility. She was diagnosed with ABPA and was started on a high dose of prednisolone, inhaled steroids (beclomethasone 250 mg metered dose inhaler two puffs b.i.d.), salmeterol (25 mg metered dose inhaler two puffs b.i.d.) and montelukast (10 mg q.d.). She …