Purpose

Among the wide spectrum of malignant, benign, and inflammatory orbital pathologies, we present a rare and, to our knowledge, previously unreported case of invasive fungal infection following tumor-free orbital exenteration in a patient on Hedgehog pathway inhibitor therapy.

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Methods

An 86-year-old patient presented as an emergency with an exophytic, nodular tumor completely obscuring the left orbital structures. CT and MRI confirmed extensive orbital infiltration without definitive evidence of bone invasion. After exploratory biopsy established the diagnosis of nodular basal cell carcinoma, systemic therapy with vismodegib was initiated to prevent further bone and intracranial infiltration pending orbital exenteration. Surgery was performed promptly under general anesthesia with clear tumor margins.
The patient failed to attend the scheduled one-week follow-up, presenting two weeks post-operatively instead. Upon bandage removal, a cloud of mold spores was released from the orbital cavity. Systemic therapy was immediately discontinued, and the patient was hospitalized for surgical debridement, irrigation, and combined intravenous antibiotic and antifungal therapy. Microbiological and histopathological analysis identified Aspergillus fumigatus. Treatment was initiated empirically and subsequently adjusted to culture results.

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Results

After over two months of systemic antifungal therapy, successful orbital reconstruction was achieved using a microvascularly anastomosed anterolateral thigh flap. Antifungal therapy remains ongoing.

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Conclusion

This case highlights that nodular basal cell carcinoma must never be underestimated and that immunosuppressive therapy — even when indicated — carries significant infectious risks that require vigilant postoperative monitoring.

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Additional Authors

First name	Last name	Base Hospital / Institution
Julian	Faber	University of Cologne – University Hospital – Department for Oral and Craniomaxillofacial Plastic Surgery
Kira Leona	Wefelmeyer	University of Cologne – University Hospital – Department of Ophthalmology
Robert Peter	Wawer Matos Reimer	University of Cologne – University Hospital – Department of Diagnostic and Interventional Radiology
Konrad Reinhard	Koch	University of Cologne – University Hospital – Department of Ophthalmology

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