This case report describes a 55-year-old man who presented with a swelling below his eye for 5 months. Surgical exploration and biopsy revealed pus and bone erosion. Histopathology showed chronic osteomyelitis due to fungal infection, identified as Aspergillus species. The patient's wound continued draining despite antibiotics. Further imaging and debridement surgery confirmed destruction of the zygomatic arch and maxilla from chronic osteomyelitis. The patient was treated with antifungal medication for 6 weeks.

1. FUNGAL OSTEOMYELITIS OF
ZYGOMATICO MAXILLARY
COMPLEX – A RARE CASE
Dr. Ghulam Saqulain
M.B.B.S., D.L.O., F.C.P.S
Head of Department of ENT
Capital Hospital, Islamabad

2. CASE HISTORY
 Name: Khawaja Abdul Rehman
 Age: 55 Years
 Sex: Male
 Admission No: 2569
 Card No: 10827 PD
 Address: H.No 8041, Sadiq
Abad Rawalpinndi
 DOA: 04.03.04 DOD: 16.03.04
 DOA: 09.04.04 DOD: 16.04.04
 DOA: 25.5.05 DOD: 29.06.05

3.  Presenting Complaint:
 Swelling below the Eye 5 months
 Past History:
 Medical No history of any significant disease
No history of allergy
 Surgical Not significant
 Family History:
 Nothing Significant
 Personal History
 Married, 3 sons and 4 daughters. No addiction.

4. EXAMINATION
GENERAL PHYSICAL EXAMINATION
A old man sitting anxiously
in bed, well oriented to
time, place and person.
 Anaemia
 Jaundice
 Clubbing
Absent
 Cyanosis
 Palpable Nodes
Contd.

5.  Temp: A febrile
 Pulse: 84 beats per min.
Regular,
 BP: 130/80 mm Hg.
…GENERAL PHYSICAL
EXAMINATION

6. SYSTEMIC EXAMINATION
 Resp. System:
 CVS:
NAD
 CNS:
 GIT:.

7. E.N.T EXAMINATION
NASAL EXAMINATION
 Inspection:
 Anterior Rhinoscopy: Normal Mucosa, turbinates and septum noted.
 Posterior Rhinoscopy: NAD
 Palpation: No Tenderness over cheeks
EXAMINATION OF THROAT
Poor oral hygiene
EXAMINATION OF EARS
Normal findings noted.

8. LOCAL EXAMINATION
 Revealed a small ovoid
swelling 1 cm x 1.5 cm on and
below the lateral part of
right infra orbital region.
The swelling was cystic in
consistency with poorly
delineated rounded margins.
No signs of inflammation
noted. Swelling was immobile

9. INVESTIGATIONS
 CP 15.03.04
 WBC 6600 ul
 NE% 63%
 Ly% 28%
 MO%06%
 EO% 03%
 Hb 15.4 g/dl
 PLT 136,000 ul
 ESR 07mm/1st hr.
 HCV Ab Negative
 HBs Ag Negative
 FBG 100 mg/dl(Range60 -110mg/dl)
 RBG 145mg/dl (Range110-
160mg/dl)
 Montoux Test: -ve
 Urea 47 mg/ dl
 Creatinine 1.7 mg/dl
 ALAT 33 U/L
 Alkaline Phos. 117 U/L
 Total bilirubin 1.9 mg/dl

10.  Plain Radiograph of
PNS
 No bone erosion
noted
 X-Ray Chest
 Normal.

11.  Provisional Diagnosis:
 Infra-Orbital Cyst
 Treatment:
 Inj. Ceftim 1 gm I/V BD
 Tab. Mytil 500 mg BD

12.  Fluid Aspirated For Cytology/ Culture
sensitivity (4.3.4)
 Fluid Cytology: Findings consistent with
Acute Inflammation/ Abscess were noted
 Culture Sensitivity: No organism found
after 48 hrs incubation at 37 degree C.

13. Follow Up
 Swelling Reappeared soon after
discharge of patient from
hospital
 Patient Readmitted for
Excision Biopsy

14. Surgical Exploration
 Surgical Exploration was planned after due
preparation
 Procedure:
 On Exposure through a horizontal incision on
right infra orbital region, a collection of pus was
found under the periosteum.
 Drainage of pus was performed along with
curettage of bone underneath.

15.  Antral lavage performed, which did not
reveal any collection of pus in Maxillary
Sinus. Also no communication was noted
between the sinus wall and cyst cavity.
 Samples sent for histopathology and
Culture Sensitivity
 More extensive surgery deferred pending
further investigations.

17. Post Operative Treatment:
 Antibiotic
 In Ward
 Inj. Ceftim 1 gm I/V BD
 Inj. Ampicillin 500 mg I/V TDS
 On Discharge
 Tab. Mytil 500 mg BD
 Cap. Kefril 500 mg TDS
 Analgesics
 Stitches Removed after a week

18.  Histopathology (21.04.04)
Chronic Non Specific Inflammation
 Culture Sensitivity
 Growth of Staph coagulase negative
(Probably skin commensal flora?)

19.  Wound
transformed into a
sinus discharging
blood and pus.
 There was no or
little response to
different groups of
antibiotics.
 Therefore Further
investigations were
planned.

20.  Repeat X-Ray PNS: (8.8.04)

21. CT Scan
31.05.05
 Destruction of zygomatic
arch and part of anterior
wall of maxilla noted on
the right side.
 Sinus tract was visualized
 Peri-orbital fat and
muscles appear normal
 Maxillary antrum, Infra
temporal fossa appears
normal.

22.  Findings are Compatiable with Chronic
Osteomyelitis

23.  Operation (18.06.05)
 Wound Debridement + Sequestrectomy +
Curettage of underlying bone + Bone
surface polished with diamond burr.

26.  Histopathology (20.06.2005) Lab #:
H-335-05.
Chronic Osteomyelitis due to Fungal
Infection. The morphology of hyphae is
suggestive of Aspergillus sp.

27.  Medical Treatment:
 Tab. Nizoral 400 mg BD. 6 weeks