No Rhabdo?

Intraoperatively, the orbital mass was firm and white. There was invasion through the orbital floor. Intraoperative frozen-section pathology consultation noted "moderately cellular spindle cell lesion with mixed inflammatory infiltrate." She was discharged home pending final pathologic diagnosis. The pediatric oncology service was contacted about meeting the patient once final pathology was known. On post-operatove day 3, her parents reported increased swelling and chemosis around the eye. On the same day, the final pathology from the initial biopsy showed granulomatous infiltration with fibrosis and fungal elements identified consistent with zygomycosis. She immediately returned to the hospital where she was admitted with a plan for surgical debulking by both otolaryngology and oculoplastic surgery. Surgery proceeded without complication and an orbital catheter was placed for direct orbital and sinus irrigation with antifungal medication. Amphotericin B was started both intravenously and intraorbitally, though the orbital catheter was dislodged on post-op day #2. Evaluation for immunosuppression was completed and revealed no evidence of systemic immunosuppression. Posaconazole therapy was added and the patient was discharged home after 10 days once it was clear that her disease was not clinically progressing. Cultures from her surgical debulking never grew any organism. She subsequently received outpatient amphotericin B IV therapy for 3 months and oral posaconazole for a total of 15 months, over which time her examination normalized and radiographic evidence of disease resolved. Orbital zygomycosis in immunocompetent patients, especially children, is a rare cause of an orbital mass mimicking cellulitis. Management includes surgical debulking, long-term antifungal medication, and evaluation for immune suppression. Emerging organisms such as Apophysomyces elegans may make these presentations more common in the future.