Chronic migraine unmasking invasive sinonasal aspergillosis: a delayed diagnosis with skull-base and cavernous sinus extension: a case report

Abstract

Invasive aspergillosis (IA) is rare infection, primarily affecting immunocompromised hosts. We report a rare case of IA in an apparently immunocompetent 54-year-old woman, initially misdiagnosed and treated as migraine due to headache and diplopia. We reviewed the patient’s clinical presentation, imaging studies (Computed tomography [CT] and Magnetic resonanace imaging [MRI]), surgical intervention, antifungal therapy, and postoperative course. Diagnostic criteria included radiologic evidence of sinus mass with bone erosion and histopathologic confirmation following functional endoscopic sinus surgery (FESS). Treatment complications were monitored through serial laboratory tests and clinical assessments. CT demonstrated bone erosion of the left maxillary sinus; MRI showed a T1-hyperintense, T2-hypointense lesion with peripheral rim enhancement. The patient underwent FESS with complete debridement. Postoperatively, voriconazole was administered according to standard dosing protocols. The patient developed syndrome of inappropriate antidiuretic hormone secretion (SIADH), which was promptly recognized and managed with fluid restriction and salt supplementation. Full remission was achieved, with resolution of neurological symptoms and normalization of sodium levels. This case underscores that IA can occur in patients without overt immunosuppression and may mimic benign neurologic conditions. Early consideration of fungal etiologies in refractory “sinus-related” neurological presentations, combined with targeted imaging and prompt surgical and antifungal therapy, can lead to favourable outcomes.