Fever, rhinosinusitis and glomerulonephritis with systemic inflammation and antimyeloperoxidase antibody

A woman in her 80s presented with a month-long fever and nasal discharge, which did not subside by clarithromycin and levofloxacin. She did not have a history of allergic diseases including bronchial asthma. Physical examination showed no significant findings. However, laboratory tests revealed a high level of C-reactive protein (129 mg/L, reference range <1.4), positive antimyeloperoxidase antibody and active urine sediments including haematuria, proteinuria and cellular casts. Whole-body CT demonstrated no remarkable findings except abnormal soft tissue filling left maxillary sinus (figure 1A). The patient was referred to our department under the suspected diagnosis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis with nasal manifestation and glomerulonephritis. However, CT reassessment revealed slight speckled calcification without bone destruction in the left maxillary sinus (figure 1B). MR fat-saturated-T2-weighted imaging also demonstrated low-intensity areas in the left maxillary sinus without dural thickening (figure 1C). In the nasopharyngoscopy procedure, the septum was found to be normal, but the lateral wall of nasal cavity was retracted with purulent discharges (figure 1D). (1-3)-β-D-glucan, serum fungal antigen and blood culture test results were negative. We suspected left fungal sinusitis and performed surgical treatment. Evaluation of the maxillary sinus indicated acute-angle branching, septate, filamentous fungi, suggesting Aspergillus spp (figure 1E). The mucosal biopsy of maxillary sinus exhibited inflammatory cells around vessels without fungal invasion (figure 1F). © 2022 BMJ Publishing Group. All rights reserved.