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Proptosis in an asthmatic patient
  1. T S Shah,
  2. P Sundaram,
  3. J D Rege,
  4. J M Joshi
  1. Department of Respiratory Medicine, T N Medical College and B Y L Nair Hospital, Mumbai
  1. Correspondence to:
 Professor J M Joshi
 Department of Respiratory Medicine, T N Medical College and B Y L Nair Hospital, Mumbai-400008, India; deptrespmedhathway.com

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Answers on p 712.

A 33 year old male non-smoking farmer was admitted to the neurosurgery services with a history of diplopia, visual loss, epistaxis, and a left orbital swelling. He was referred to us for preoperative evaluation in view of chest radiographic opacities. He had cough with mucoid sputum, breathlessness for two years, and had been treated with antituberculosis drugs for the same.

On clinical examination he had proptosis of the left eye and respiratory system examination revealed bilateral ronchi and crackles. There were fleeting nodular opacities on serial chest radiographs. His sputum for acid fast bacilli was negative on several occasions. Laboratory examination showed a normal blood count, renal and liver profile. Serum IgE concentration was greater than 1000 IU/ml (normal values 20–100 IU/ml), cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA) was positive with a titre of 1:20 (positive >1:10), and specific IgE for Aspergillus fumigatus was positive. Spirometry showed an obstructive abnormality with poor bronchodilator reversibility.

High resolution computed tomography of the chest showed bilateral cystic bronchiectasis with mucoid impaction (fig 1). Magnetic resonance imaging (MRI) of the orbit with sinuses revealed a large mass involving the left ethmoidal and maxillary sinuses (fig 2) with involvement of the floor of the orbit and extension into the medial, lateral recti, and inferior and superior orbital fissure. The optic nerve was compressed with adjacent cavernous sinus erosion. The patient was treated with inhaled bronchodilators, oral steroids, and was subjected to surgery for his orbital tumour. Histopathology of the tumour showed a film of collagenous tissue, bits of degenerative bony tissue hyalinisation, inflammation, and giant cells within which were a few filamentous structures with short acute angled hyphae (fig 3). There was no vasculitis.

Figure 1

High resolution computed tomogram of the chest showing areas of mucoid impaction with bilateral bronchiectasis.

Figure 2

MRI of the orbits and sinuses showing a mass involving the left ethmoidal and maxillary sinuses.

Figure 3

Photomicrograph of the histopathology slide of the operated orbital mass.

QUESTIONS

  1. What is the diagnosis of this respiratory condition?

  2. Which respiratory diseases have coexistent sinus and orbital involvement and what was the cause in this patient?

  3. What is the significance of C-ANCA in chronic lower respiratory tract infections?

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