A Difficult Bug to Swallow

A whole body CT and PET scan revealed metastatic disease with enhancement at the left orbital apex, numerous lung nodules, numerous lymph nodes within the chest, mediastinum, axilla, and pelvis, enhancement of the spleen, the right adrenal gland, and numerous musculoskeletal lesions including the spine. Following the imaging studies and discussion with the oncologist the patient elected for conservative treatment. He passed away within 2 weeks of presentation without knowledge of the location of the primary cancer. An autopsy was performed that revealed poorly-differentiated adenocarcinoma with signet ring features within the patient's esophagus and within all metastatic lesions. There was no evidence of Aspergillus infection in the orbital apex and it is felt this was normal flora that was isolated from the nasal swab. Metastatic disease is a rare cause of orbital apex syndrome. More commonly infectious, inflammatory, or local neoplastic processes are the culprit. The most common malignant tumors to metastasize to the orbital apex are cancers of the breast, lung, or kidney, and malignant melanoma 1,2 . Adenocarcinoma of the esophagus is the most common type of esophageal carcinoma in the United States. At the time of diagnosis it is not uncommon for it to have spread locally or to have metastasized to distant locations. The most common metastatic locations in order of frequency include regional lymph nodes, liver, lung, bone, adrenal glands, and peritoneum 3. Metastasis involving the orbital apex is extremely rare and it is even more rare for this to be the presenting sign and symptom of the disease.