Reverse masquerade syndrome: Fungal adnexal infection mimicking carcinoma in a HIV-positive patient
A known HIV-positive, 48-year-old male patient on Highly Active Anti Retroviral (HAART) therapy for the last 4 months and anti-tubercular therapy (ATT) since the last 3 months, presented with a painless, rapidly progressive ulcerated lesion involving the conjunctiva, lids, and anterior orbit of the right eye for past 3 weeks. According to the patient, the lesion started as a small boil over the right upper lid, which rapidly increased in size. Then, he developed a swelling over the medial canthal area. Both the lesions bled to touch. The patient gave history of decrease in vision in the right eye over the last 10 days. Best corrected visual acuity in the right eye was perception of light with inaccurate projection of rays and that of the left eye was 6/6; N6 (Snellen). The anterior segment examination of the left eye was within normal limits. Fundus examination of left eye revealed cotton-wool-spots and flame-shaped hemorrhages in the periphery suggestive of AIDS-related retinal microvasculopthy.[] The right eye conjunctiva was congested with a sloughed-out area measuring 1 × 0.5 cm with underlying scleral thinning. The cornea showed an epithelial defect and thinning with extensive keratinization. The upper lid showed a 2.5 × 1 cm full-thickness defect with an overlying black eschar and a medial canthal ulcerative lesion []. Ultrasound B scan of the right eye was within normal limits. Routine blood investigations were within normal limits, except mild decrease in hemoglobin levels (8.6 mgm/dl). Erythrocyte Sedimentation Rate was raised to 128 mm/h. CD4 lymphocyte count was 100 cells/μl and viral load of 101 copies of RNA/ml.\nMagnetic resonance imaging (MRI) revealed a soft tissue lesion in the right supero-medial extra-conal space associated with thickening of extra-ocular muscles []. Considering the above findings in this immuno-compromised patient, the differential diagnoses were squamous cell carcinoma of the lid with extension into the orbit and zygomycosis. The patient was accordingly taken up for incisional biopsy of the periocular lesion for definitive histopathological diagnosis. Surprisingly, no malignant cells were found in the biopsy specimen. Gomori methenamine silver stain (GMS) staining showed plenty of fungal filaments []. Part of the specimen was also sent for microbiological analysis that showed presence of numerous budding yeast cells on KOH/Calcofluor-white stain []. Culture confirmed it as Candida albicans. The patient was started on IV fluconazole 600 mg once daily for 14 days after discussion with an infectious disease specialist. Topical antibiotic drops and lubricants were continued. HAART therapy and ATT were continued.\nOn his next follow-up visit, the patient had responded significantly to this therapy. The lid defect had healed. There were symblepharon and lagophthalmos of 7 mm. Cornea was opaque and keratinized []. Temporary tarsorrhaphy was performed, and he was advised to undergo symblepharon release with amniotic membrane transplantation with full thickness skin graft of right upper lid. Repeat MRI revealed significant resolution of the lesion [].