Abstract Listings 2024

Purpose

To showcase a rare case of a massive eroding skull lesion, infiltrating the orbit which grew over 10 years as a result of psychiatric isolation- Agoraphobia. We aim to illustrates the complexities of managing the psychosocial and physical impacts of this extensive lesion through imaging, surgery and an MDT approach.

Methods

A 47-year-old man with severe agoraphobia and clinical OCD presented with a right fronto-temporal erosive skull lesion, exposed bone, pulsating brain tissue, and purulent discharge from both the skull lesion and right eye. The lesion had developed over a decade, exacerbated by the patient’s habit of picking at a scalp scab, leading to an ulcerating wound. Agoraphobia started at school, finished school but never worked. Family history revealed father with history of Basal Cell Carcinoma (BCC) and a brother with agoraphobia. Ocular Examination: Extensive erosion of the upper eyelid margin, conjunctival chemosis with purulent discharge, sluggish pupil, impaired ocular motility, and a small non-staining stromal opacity.Systemic Examination: Neurologically intact but pale with mild tachycardia, possible systolic murmur, and vascular and ulcerating skin lesions on the right upper arm, chest, and back.Laboratory Tests: Severe iron deficiency anaemia, low lymphocyte count, high neutrophils, and elevated PT/INR ratio.Imaging Results: Large erosive defect in the right frontal bone, zygoma, and orbit with herniation of the frontal lobe.Soft tissue involvement extending into the pre-septal and post-septal extraconal orbital compartments and the right frontal sinus. Possible dura and leptomeningeal involvement, but intact intraconal features and optic nerve.Differential Diagnoses: Granulomatous lesions, Infectious etiologies, Neoplastic conditions (e.g., tuberculosis, BCC, granulomatosis with polyangiitis, Gorlin-Goltz syndrome, trigeminal trophic syndrome)Initial Treatment: Blood transfusion for severe anemia, IV ceftriaxone for infection, Incisional biopsies from skull, eyelid, arm, back, and chest lesions

Results

Biopsy results confirmed the presence of infiltrative and nodular BCC. Given the extensive involvement of the skull, brain, and orbital structures, a multidisciplinary team (MDT) discussion comprising experts from Neurosurgery, Oculoplastic, Plastic Surgery, Radio-oncology, and Maxillofacial, was held to formulate a surgical management plan. A joint surgical procedure planned to address the extensive disease involvement.

Conclusion

This case exemplifies the consequence of psychiatric comorbidities on a patient’s physical health. Agoraphobia is associated with poorer health related Quality of Life and in this case may have uniquely presented with poor levels of health utilization in comparison to other anxiety related health disorders. No specific studies were found in the context of agoraphobia exacerbating cancer or chronic conditions, however few studies have correlated adverse phycological impacts of oculoplastic procedures such as social phobia, generalised anxiety and depression. BCC cancers are slow growing respond well to early treatment and excision. A similar case study identified comparable extension of a facial BCC and highlighted the necessity more aggressive intervention in such cases. The unique presentation of multiple skin lesions alongside the agoraphobia indicated immediate stabilization, multisystem review and multifactorial decision making in for the management of this patient.

Additional Authors

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