Chemotherapy For Acute Promyelocytic Leukemia Research Articles

Disseminated Scabies During Induction Chemotherapy for Acute Promyelocytic Leukemia.

Anahtar Kelimeler: Lösemi, skabies, deri.

Long-term retrospective study of retinoic acid combined with arsenic and chemotherapy for acute promyelocytic leukemia.

Chemotherapy, all-trans retinoic acid (ATRA), and arsenic are effective options for acute promyelocytic leukemia (APL). We conducted a 20-year retrospective analysis of newly diagnosed (ND) APL patients treated with arsenic, ATRA and mitoxantrone. After achieving complete remission (CR), patients received 3-5 cycles of chemotherapy followed by AS4S4 maintenance for 3years. Eighty-eight ND APL patients were treated with either oral AS4S4 (n = 42) or arsenic trioxide (ATO) (n = 46). The 8-year overall survival (OS) rate was 100% in the AS4S4 group and 90% in the ATO group. The disease-free survival (DFS) rates were 100% and 87.1% (p = 0.027), respectively. Patients in the ATO group had more side effects. A subsequent cohort of 33 ND APL patients received triple therapy with oral AS4S4, ATRA, and chemotherapy. The 13-year OS and DFS rates were 100% and 90.9%. Our long-term analyses show that APL patients with oral AS4S4 had better outcomes compared to ATO, with no need for hospitalization.

Complications during Induction Chemotherapy in Acute Promyelocytic Leukemia: An Institutional Experience.

Stalin Chowdary BalaIntroduction Acute promyelocytic leukemia (APL) has transformed from a highly fatal disease to a highly curable one. Induction deaths continue to represent one of the major impediments in modern therapy of APL. Sepsis, hemorrhage, and differentiation syndrome are the major complications during induction therapy in APL. The present study reports the incidence and prognostic factors of major complications during induction chemotherapy in patients with newly diagnosed APL. Materials and Methods The present study was a single institutional, observational, retrospective study. All cases of APL diagnosed by morphology and confirmed by RT PCR (PML RARα) were included in this study. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Results A total of 73 patients were analyzed. The median age at presentation was 30 years (range, 3-60 years) with a female to male ratio of 1.02:1. The most common symptom at presentation was fever (80%), followed by fatigue (56%) and gum bleeding (37%). The majority of the patients at presentation were high risk (42.4%), followed by intermediate risk (38.4%) and low risk (19.2%). Fifty-seven (78%) patients achieved complete hematological remission and 16 (22%) succumbed during induction chemotherapy. Infection was the most common cause of induction death (50%), followed by hemorrhage (37.5%) and differentiation syndrome (12.5%). On univariate analysis of prognostic factors, bcr3 variant, grade 3/4 bleeding during induction, and low levels of albumin at presentation were significant for induction mortality ( p = 0.034, 0.041, and 0.008 respectively). On multivariate analysis, only serum albumin < 3.5 g/dL was an independent predictor for induction mortality ( p = 0.043). Conclusion The majority of patients were high risk at presentation. Sepsis was the most common complication during induction and also the leading cause of induction death. Identifying induction complications at the earliest and providing aggressive supportive measures can further improve outcomes in APL.

Long-term follow-up results of cytarabine-containing chemotherapy for acute promyelocytic leukemia.

Background/AimsWe evaluated the feasibility and long-term efficacy of the combination of cytarabine, idarubicin, and all-trans retinoic acid (ATRA) for treating patients with newly diagnosed acute promyelocytic leukemia (APL).MethodsWe included 87 patients with newly diagnosed acute myeloid leukemia and a t(15;17) or promyelocytic leukemia/retinoic acid receptor alpha (PML-RARα) mutation. Patients received 12 mg/m2/day idarubicin intravenously for 3 days and 100 mg/m2/day cytarabine for 7 days, plus 45 mg/m2/day ATRA. Clinical outcomes included complete remission (CR), relapse-free survival (RFS), overall survival (OS), and the secondary malignancy incidence during a 20-year follow-up.ResultsThe CR, 10-year RFS, and 10-year OS rates were 89.7%, 94.1%, and 73.8%, respectively, for all patients. The 10-year OS rate was 100% for patients that achieved CR. Subjects were classified according to the white blood cell (WBC) count in peripheral blood at diagnosis (low-risk, WBC < 10,000/mm3; high-risk, WBC ≥ 10,000/mm3). The low-risk group had significantly higher RFS and OS rates than the high-risk group, but the outcomes were not superior to the current standard treatment (arsenic trioxide plus ATRA). Toxicities were similar to those observed with anthracycline plus ATRA, and higher than those observed with arsenic trioxide plus ATRA. The secondary malignancy incidence after APL treatment was 2.7%, among the 75 patients that achieved CR, and 5.0% among the 40 patients that survived more than 5 years after the APL diagnosis.ConclusionsAdding cytarabine to anthracycline plus ATRA was not inferior to anthracycline plus ATRA alone, but it was not comparable to arsenic trioxide plus ATRA. The probability of secondary malignancy was low.

Успішне лікування легеневого туберкульозу в дитини, хворої на гостру промієлоцитарну лейкемію, на тлі інтенсивної хіміотерапії

The predisposition of patients with acute leukemia (АL) to various infectious complications is a well-known fact. The reason is a decrease in immunity due to the underlying disease and due to the use of immunosuppressive cytostatic and radiotherapy. Tuberculosis infections (TIs) are serious and life-threatening complications in patients with malignant hematological disorders and recipients after hematopoietic stem cell transplantation. Verification of tuberculosis (TB) is often delayed among patients with hematooncological diseases due to low suspicion and due to the search for other infectious complications. Those with the involvement of the respiratory system are the most common complications in immunologically compromised patients. In acute leukemia, the TB process may have been underestimated, due to negative tests for mycobacterium tuberculosis (MBT), and patients with neoplasia are often prescribed antibacterial agents such as amikacin and ftorchinolones, which are also effective against TI. We describe a 10-year-old boy who was diagnosed with pulmonary tuberculosis, a disseminated form complicated by hydrothorax, during induction chemotherapy for acute promyelocytic leukemia (APL). For diagnostic purposes, repeated punctures of the pleural cavity with drainage of pathological effusion and diagnostic and remedial bronchoscopy were performed, bacterial pneumonia and systemic mycosis were suspected. The diagnosis of TB was verified on the basis of positive PCR test for TB, molecular genetic study of sputum, bronchial lavage for the presence of genome of MBT without resistance to rifampicin, sputum microscopy, while sputum culture and pleural fluid were negative for MBT. TB treatment was coEadministered with AML-BFM 2004 intensive cytostatic therapy without dose reduction of cytostatics. The child was prescribed intensive tuberculostatic therapy with 4 drugs (rifampicin + isoniazid + pyrazinamide + inbutol) for 3 months and subsequent maintenance antituberculous chemotherapy with two drugs for 4 months (rifampicin + isonimazide). With this analysis, we advocate the need for early suspicion of TB in patients receiving treatment for AL. The results of our study suggest that antitumor chemotherapy is not an obstacle to effective TB-treatment. The described patient is in remission of AML and TB for 21 months. The research was carried out in accordance with the principles of the Helsinki declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: acute promyelocytic leukemia, tuberculosis, cytostatic therapy, children.

Efficacy and Safety of the Induction Therapy with Different Doses of Anthracyclines for Patients with Newly Diagnosed Acute Promyelocytic Leukemia

The clinical data of 129 consecutive hospitalized newly diagnosed APL patients from January 2011 to December 2017 were collected and retrospectively analyzed. Sixty-six patients received arsenite, ATRA and anthracyclines of low doses (low dose group), while other 63 patients received arsenite, ATRA and anthracyclines of standard doses (standard dose group), the efficacy and safety were compared and analyzed in 2 groups. There were no statistically significant differences in terms of age, sex, routine blood indexes,LDH level, bone marrow promyelocyte count,prognostic stratification between patients in two groups (P>0.05). During the treatment, WBC count peak and its time point were not significantly different between two groups (P>0.05). Both induction regimens showed good efficacy, the PML-RARα gene conversion rate from positive into negative, the 2-year overall survival rate and disease-free survival rate in the low-dose group were similar to those in the standard dose group(P＞0.05). The recovery time of neutrophils and platelets in the low-dose group was 0 d and 11 d, respectively, which were statistically  significantly shorter than those in the standard dose group (3 d,15 d) (both P=0.000). The median value of platelet and erythrocyte transfusion in the low-dose group was 6.9 U and 4.2 U, respectively, which were statistically significantly lower than that in the standard dose group (8.4 U,6.8 U) (P=0.037，0.000). And the inpatient time in the low and the standard dose groups were 30.98 and 30.71 days, respectively (P=0.770). For newly diagnosed patients with APL, the efficacy was similar between induction therapy containing arsenite,ATRA and low dose anthracyclines and the induction therapy containing arsenite, ATRA and standard dose anthracyclines, however, the former appears even safer.

A Case of Multiple Hepatic Microabscesses due to Mycobacterium simiae

Introduction:Mycobacterium simiae is an atypical mycobacterium which can produce disseminated disease in patients with HIV and other immunodeficiency states. Herein, we describe a unique case of Mycobacterium simiae which presented initially as diarrhea with subsequent dissemination to the liver and spleen. Case Report: A 41-year-old Hispanic female on chemotherapy for acute promyelocytic leukemia presented with lower abdominal pain, diarrhea and fever of 102.2F. On physical examination, she had mild lower abdominal tenderness. Labs revealed a WBC count of 0.4 with 2% neutrophils and 98% lymphocytes; HIV test was negative. Patient was managed as neutropenic fever. Initial CT scan of abdomen was normal. She remained febrile despite being on broad spectrum antibacterial, antifungal and antiviral agents. Septic work-up (including bone marrow culture, whole body gallium scan and transesophageal echocardiogram were negative. Repeat CT scan performed a week after hospitalization revealed mesenteric lymphadenopathy, mostly in the left ileo-colic distribution. A follow-up scan two weeks later showed multiple tiny lucencies throughout the liver and spleen, consistent with microabscesses (see Figure). Stool culture at four weeks grew Mycobacterium simiae. Liver enzymes were persistently normal. Bacterial, fungal and AFB cultures of liver biopsy tissue were negative on two separate occasions. Quadruple antitubercular therapy was thereafter initiated with rapid defervescence and clinical improvement. Discussion: This case illustrates the importance of considering atypical mycobacteria when dealing with immunocompromised patients presenting with intractable fever. To our knowledge, this is the first reported case of hepatic microabscesses attributed to Mycobacterium simiae.Figure: [1038] CT scan abdomen showing multiple microabscesses throughout the liver and spleen.

Clinical and genetic features of therapy-related myeloid neoplasms after chemotherapy for acute promyelocytic leukemia

AbstractAcute promyelocytic leukemia (APL) is a highly curable disease with excellent complete remission and long-term survival rates. However, the development of therapy-related myeloid neoplasms (t-MN) is being reported with increasing frequency in patients successfully treated for APL. We attempted to clarify the different clinical features and hematologic findings between t-MN and relapse cases, and to identify gene alterations involved in t-MN. We compared 10 relapse and 11 t-MN cases that developed in 108 patients during their first complete remission from APL. At APL diagnosis, t-MN patients had lower white blood cell counts than did relapse patients (P = .048). Overall survival starting from chemotherapy was significantly worse in t-MN patients than in relapse patients (P = .022). The t-MN cases were characterized as CD34+/HLA-DR+ and PML-RARA−, and 4 RUNX1/AML1 mutations were detected. T-MN is easily distinguished from APL relapse by evaluating these hematologic features, and it may originate from primitive myeloid cells by chemotherapy-induced RUNX1 mutations.

Acute promyelocytic leukemia relapsing as secondary acute myelogenous leukemia with translocation t(3;21)(q26;q22) and RUNX1–MDS1–EVI1 fusion transcript

Acute promyelocytic leukemia (APL) is a subtype of acute myelogenous leukemia (AML) that is characterized by peculiar clinical and biologic features, including severe hemorrhagic diathesis, specific recurrent chromosomal aberration, and distinct morphologic features with predominant pathologic promyelocytes. A reciprocal translocation involving chromosomes 15 and 17, t(15;17)(q22;q21), is a characteristic feature of APL that represents ∼5–8% of AML. The rearranged gene created by this translocation encodes a chimeric protein PML–RARA that is a transcriptional repressor. In contrast to other AML subtypes, APL is particularly sensitive to treatment with all trans-retinoic acid (ATRA) combined with chemotherapy, converting this once fatal leukemia to a highly curable disease. Nonetheless, therapy-related myelodysplastic syndrome–acute myelogenous leukemia (t-MDS/AML) has been reported as a rare complication of chemotherapy in APL. Of 30 APL cases described as t-MDS/AML in the literature, only 1 case relapsed as acute leukemia with t(3;21)(q26;q22). Here we describe a rare case of APL relapsing as secondary AML with t(3;21)(q26;q22) and clinically characterize this patient using the RUNX1 (previously AML1)– MDS1– EVI1 fusion transcript (with follow-up for 55 months), and review the relevant literature.

Poor results with intensified maintenance chemotherapy in acute promyelocytic leukemia

Poor results with intensified maintenance chemotherapy in acute promyelocytic leukemia

Syndrome of inappropriate secretion of ADH after administration of intrathecal chemotherapy in acute promyelocytic leukemia with empty sella of pituitary gland

Dear Editor, A 66-year-old woman who had developed acute promyelocytic leukemia was admitted with bicytopenia and administered all-trans-retinoic acid (45 mg/m), idarubicin (12 mg/m for 3 days), and cytarabine (Ara C 100 mg/m for 5 days). She first obtained remission 40 days after the administration of induction therapy. Then she was administered two courses of consolidation therapy (first course: Ara C 200 mg/m for 5 days and mitoxantrone 7 mg/m for 3 days; second course: Ara C 150 mg/m for 5 days and daunorubicin 40 mg/m for 3 days), resulting in complete remission. Before the third course, she was administered intrathecal chemotherapy [IT; methotrexate (MTX) 15 mg, Ara C 40 mg, prednisolone (PSL) 10 mg]. Chemotherapy was performed after the administration of IT. She daily ingested almost 2,500 ml of liquid, which contained an infusion of drip, and her urine totaled from 1,600 to 3,700 ml (average of 2,600 ml). She developed hyponatremia after the administration of IT. On the 5th day of IT, the patient developed general fatigue followed by a gradual disturbance of consciousness. As indicated in Fig. 1, her serum sodium level had fallen to 109 mEq/l (normal range 135 to 147 mEq/l), and plasma osmolarity was 229.5 mOsm/kg H2O (normal range 280 to 300 mOsm/kg H2O) without edema. After treatment with hypertonic saline infusion and minocycline hydrochloride (MINO), she gradually regained consciousness. On the 7th day of IT, her serum sodium level had recovered to 130 mEq/l. Plasma osmolarity was still 277 mOsm/kg H2O, urine osmolarity was 578 mOsm/kg H2O (normal range 500 to 800 mOsm/kg H2O), and her ADH level was 1.0 pg/ml (normal range 0.3 to 3.5 pg/ml). Magnetic resonance imaging (MRI) of the pituitary gland showed only neurohypophysis (lobus posterior) (Fig. 2). Her symptoms and abnormal laboratory data completely disappeared 1 month after the IT. Inappropriate secretion of ADH (SIADH) is characterized by water retention, hyponatremia, and central nervous system symptoms. SIADH can be induced by various causes, including central nervous disorders, endocrine diseases, paraneoplastic syndromes, and anticancer agents such as vincristine and cyclophosphamide [1–4]. On the other hand, MTX and PSL have not been reported to be the causative agents of SIADH. Just a single investigator reported that one of thirteen patients with a high dosage of intravenous Ara C (3–7.5 g/m) developed SIADH, but not in a patient with IT [5]. This case lacked any viral infection or disease recurrence, and the administration of IT was only evident after the development of SIADH. One reason the patient developed SIADH is thought to reflect the Ann Hematol (2007) 86:149–150 DOI 10.1007/s00277-006-0199-9

Durable molecular remissions with a single cycle of timed sequential consolidation chemotherapy in acute promyelocytic leukemia

In a pilot study to reduce the duration of treatment and potential long-term toxicities, 39 patients with acute promyelocytic leukemia in remission received a single cycle of intensive consolidation therapy, followed by intermittent ATRA maintenance. Consolidation therapy required prolonged hospitalization and was associated with a high incidence of mucositis (43% grade II or greater) and documented infection (45%). No deaths occurred during consolidation. Seven patients have relapsed; all other patients are in molecular remission (median follow-up, 2.75 years). Kaplan-Meier estimate of 3 year disease-free survival is 73% (95% confidence interval 55-91%). The relapse rate (0.06 relapses/patient-year of follow-up) is well within the range of larger published series that administer more prolonged consolidation. One patient has developed secondary myelodysplastic syndrome. These pilot data suggest that decreasing the total duration of consolidation chemotherapy did not compromise disease-free survival for APL patients induced with ATRA/anthracycline and given intermittent ATRA maintenance. However, the toxicity of the consolidation module and the development of secondary myelodysplasia despite decreased total therapy emphasize the need to further improve and refine curative therapy for APL.

News and Traditional Indications from Short Daily Dialysis: Different Schemes to Optimized ESF Response

Interest in quotidian (daily) hemodialysis (DHD) seems to be growing. DHD improves quality of life, blood pressure control, and nutrition, and decreases the need of medications, including erythropoiesis stimulating factors (ESF). We evaluate the short daily dialysis (SDHD) efficacy in 14 patients in conventional hemodialysis (HD) (3 weekly sessions/4 h), mean age 52.1 years, range 25–75, 10 males and 4 females, and found that they needed to increase dialysis efficiency by different medical indications: in 11 cases traditional indications – 5 cases with hypertensive myocardiopathy and severe LVH (2 of them with low left ventricle ejection fraction), 2 cases with symptomatic, ischemic cardiopathy 2 patient with big body‐surface area and elevated phosphorus levels, and 2 patients by inadequate dialysis (infradialysis conditioning malnutrition status) secondary to HD with permanent catheter. In one female (25 yr old), SDHD was prescribed to improve cardiac toxicity secondary to chemotherapy for acute promyelocytic leukemia. The index resistance of ESF decreased since the first month, and the Aranesp doses decreased by more than 40%. 1 male (49 years) with nephrogenic fibrosing dermopathy showed skin lesions with osteoblastic transformation. The skin lesions were improving since the first week, obtaining a decrease of the index resistance ESF higher than 60% in the first month. 1 male with symptomatic obstructive hypertrophic myocardiopathy showed improvement of symptoms and quality of life since the first weeks, as well as echocardiograpic signs and improvement in Hb levels and decreasing dose of ESF. The schedule in all of them was 5–6 days/week sessions between 2.15 h and 3 h, depending on body‐surface area. To obtain a weekly Kt/V nearest to 4, HD sessions were realized in the hospital (7 pts) or in satellite unit (7 pts). The time remaining in this schedule was between 1 and 42 months. All the patients showed clinical improvement, subjective and objective, since the first week of start of SDHD. 3 patients could be included in Tx waiting list again. Anemia improved, decreasing index resistance of ESF. In relation with this, the time necessary to improve the response to ESF was different, showing a decrease in the first month higher than 40% in two cases dialyzing with a membrane high‐flux with pore size 100 A, appearing high Hb levels also in a polycystic patient always without ESF. We observed by analyzing the results in 12 stable patients; the patients with high‐flux dialyzers showed better response to ESF. Perhaps it could offer a better clearance of large molecules (inhibitor erythropoiesis factor and high molecular weight toxins) that participate to respond to ESF.Conclusion: Our experience shows new indications for SDHD with very good results. Anemia was improved in relation with SDHD, when synthetic high‐flux membranes and high pore size were used.

Life Threatening Acute Epiglottitis in Acute Leukemia

We report an 8-year-old boy who developed a life-threatening acute epiglottitis during induction chemotherapy for acute promyelocytic leukemia. He survived the infection with emergency tracheostomy, treatment with broad spectrum antibiotics and amphotericin, and the use of granulocyte-macrophage colony stimulating factor. No organism was identified. A literature review identified 18 cases of acute epiglottitis in cancer patients. Sixteen of them were suffering from hematologic malignancies and three patients had received bone marrow transplantation. Unlike the usual case of epiglottitis, the majority (15 out of 18) of affected patients were adults and none of the infections was associated with Haemophilus influenzae. Streptococcus pneumoniae and Candida albicans were the most frequently identified pathogens. Early recognition and aggressive supportive care are required for successful management.

Fluorescence in situ hybridization: a highly efficient technique of molecular diagnosis and predication for disease course in patients with myeloid leukemias

The accuracy of cytogenetic diagnosis in the management of hematological malignancies has improved significantly over the past 10 years. Fluorescence in situ hybridization (FISH), a technique of molecular cytogenetics, has played a pivotal role in the detection of unique sub-microscopic chromosomal rearrangements that helped in the identification of chromosomal loci, which contain genes involved in leukemogenesis. We studied the feasibility and sensitivity of the FISH technique for molecular analysis of translocations markers, t(9;22) and t(15;17) for accurate molecular diagnosis and for monitoring the disease in 21 patients with chronic myeloid leukemia (CML) who received interferon-α and/or chemotherapy (7 patients), bone marrow transplantation (14 patients), and 14 patients with acute promyelocytic leukemia (APL) who received all-trans-retinoic acid (ATRA) and/or chemotherapy. We also applied conventional karyotyping (CK) for identification of t(9;22) and t(15;17) at diagnosis. All CML cases had a Ph; t(9;22) and except for two cases all APL had t(15;17). The FISH studies on CML marrows in complete cytogenetic remission (CCR) (100% Ph− by CK) achieved by IFN-α, showed 0–2.5% of cells with BCR-ABL fusion in first cytogenetic remission (Controls, range 0.5–1.5%). Repeat follow-up FISH studies could be done in two cases in remission, which demonstrated 0–10% of cells with BCR-ABL fusion. Evaluation of Ph positive status of CML marrow at diagnosis by CK (100% Ph+ cells) and FISH (80–92% BCR-ABL fusion) pointed the existence of dormant clone of normal residual hematopoietic cells along with actively proliferating clones of Ph positive cells. Flourescence in situ hybridization analysis of post-BMT CML marrows in CCR (0% Ph+ mitoses) could detect MRD with range of 1–6%. Among 14 patients, 9 who showed percentage of BCR-ABL positive cells (0.0–1.5%) almost similar to normal controls, 6 patients had comparatively good prognosis (disease-free survival 7–14 months). Of five patients with residual leukemic cells in the range of 2–6%, 4 relapsed within a period of 3–24 months. Fourteen APL patients in CCR [100% t(15;17) negative cells by CK] were evaluated by FISH to check the presence of residual leukemic cells. In these patients FISH could efficiently detect 1–14.5% of residual cells with PML-RARA (patients mean MRD 5%, controls mean MRD 3.5%, P=.02). Since the time of FISH analysis, 5 to 7 patients with higher fraction of leukemic cells (5–11%) relapsed within a short period (1–7 months). On the contrary, 5 of 7 patients with either absence or low percentage of PML-RARA positive cells remained in complete remission for 11–24 months. Our data show that FISH has a potential to detect and measure the fraction of aberrant malignant cells in remission marrows, induced by BMT in CML and chemotherapy in APL. These findings encourage the investigations on a large scale to merit its potential for identification of patients at high risk. In the present studies, FISH on interphase cells also demonstrated its efficiency in the molecular diagnosis by its ability to detect BCR-ABL and PML-RARA fusion in CML with masked/variant Ph and t(15;17) negative APL, respectively. The efficiency of technique in molecular diagnosis was also proved in one of the CML patients who progressed to myeloid blastic phase where interphase FISH could identify an extra BCR-ABL fusion on both chromosomes 9 indicating insertion of BCR into ABL and its duplication.

Role of maintenance chemotherapy in acute promyelocytic leukemia.

The effect of maintenance chemotherapy on remission duration was analyzed in 39 of 70 patients (56%) with acute promyelocytic leukemia (APL) who achieved complete remission on induction chemotherapy. Overall, the median remission duration was 26 months, with a 3-year remission rate of 42%. The 3-year remission rate was significantly higher in patients who received 6-mercaptopurine and methotrexate (POMP) during maintenance, compared with those who did not (56% versus 30%; P less than 0.01), and in patients who received long-term maintenance therapy (P less than 0.01). A multivariate regression analysis selected maintenance therapy with POMP to be the only statistically significant factor associated with long-term remission duration. The type of maintenance chemotherapy is important in overall prognosis of patients with APL, and should be investigated further.

Invasion of paranasal sinuses by Aspergillus oryzae

A 24-year-old male patient receiving chemotherapy for acute promyelocytic leukemia developed fever, right periorbital swelling and mild right proptosis. A head scan showed opacification of the right maxillary and ethmoid sinuses with adjacent soft tissue swelling. Biopsy of the nasal mucosa demonstrated the typical septate hyphae of Aspergillus species which was later shown on culture to be Aspergillus oryzae. A. oryzae has only rarely been reported in human disease and there is confusion as to its precise identification and role. We would like to confirm the pathogenicity of A. oryzae with this uncommon presentation of aspergillosis and also emphasize the need to take adequate and multiple cultures in suspected cases so that the possibility of species identification will be maximized.