Antibiotic-Refractory Sinusitis FREE

A 64-year-old man with a history of chronic sinusitis presents withleft periorbital swelling and subtle left ptosis (Figure 1). His past medical history is otherwise unremarkable. He was treated with amoxicillin-clavulanate, 875 mg/125 mg, twice per day for 10 days for presumed sinusitis. He experienced mild temporary improvement. Symptoms recurred within a month, and he was given a second course of amoxicillin. Physical examination reveals worsening left periorbital swelling, unilateral nasal blockade, and persistent subtle left ptosis. The neurological examination results are normal, and ptosis is thought to be secondary to palpebral swelling. Lymphadenopathy and hepatosplenomegaly are absent. Laboratory test results are unremarkable.

A. Perform computed tomography of the head.

B. Obtain hemoglobin A_1c level to explore the etiology of ptosis.

C. Prescribe a third cycle of antibiotics but change to amoxicillin-clavulanate.

D. Prescribe antihistamine agents.

See www.jama.com for online Clinical Challenge.

Diffuse large B-cell lymphoma of the frontal sinus

A. Perform computed tomography of the head

The key feature in this case is to recognize that malignancy is part of the differential diagnosis of supposed antibiotic-refractory infections and that diffuse large B-cell lymphoma has a variety of presentations.¹

The most common etiology of sinusitis is viral. Despite literature confirming the lack of efficacy of antibiotics for acute rhinosinusitis, antimicrobial drugs continue to be frequently prescribed for this condition.² However, the uncommon location and recurrence of this patient's episodes of sinusitis helped ruled out other possible etiologies. Therefore, prescribing antihistamine agents or further courses of antibiotics would not have been appropriate. Poorly controlled diabetes mellitus with neuropathy is a cause of ptosis, although it is an unlikely diagnosis in a patient with normal laboratory results, including serum glucose. Nasal and sinus endoscopy may have a role in cases of chronic rhinosinusitis or antibiotic-refractory sinusitis because, rarely, sinonasal pathology might be caused by sarcoidosis, Wegener disease, or tumors. Clinical presentations that should raise suspicion for malignancy include unilateral lesions, nasal blockade, epistaxis, and olfactory changes.³

In 2008 there was a reclassification of lymphoid malignancies from the Rappaport classification, Kiel Lymph Node Registry, Revised European-American Lymphoma (REAL) to the World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues.^4- 5 Non-Hodgkin lymphoma (NHL) accounts for the majority of all lymphomas, whereas diffuse large B-cell lymphoma is the most common NHL. Non-Hodgkin lymphoma of the sinonasal tract is an uncommon neoplasia, representing 1.5% of NHLs.⁶ The occurrence of primary NHL in the frontal sinus is extremely rare.

Computed tomography of the head showed a mass extending into the left ethmoid and frontal sinuses (Figure 2). The patient underwent frontal sinus exploration, confirming CD20-positive cells (Figure 3) with high MIB that displayed medium to large cells with round to oval nuclei and a moderate amount of cytoplasm on hematoxylin-eosin stain, compatible with a diagnosis of diffuse large B-cell lymphoma. Bone marrow biopsy was negative for lymphoma. The patient was treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], and prednisone) and intrathecal prophylactic methotrexate.^7- 8 This therapy resulted in complete remission of his lymphoma. Adverse effects included chemotherapy-induced alopecia and onycholysis.