J Korean Ophthalmol Soc.  2013 Mar;54(3):540-544. 10.3341/jkos.2013.54.3.540.

A Case of Invasive Aspergillosis Involving the Orbital Apex and Occipital Lobe:Successful Treatment with Voriconazole

• Lim SH
• Sung SH
• Lim KH

• KMID: 2216780
• DOI: http://doi.org/10.3341/jkos.2013.54.3.540

Abstract

PURPOSE
To report an immunocompetent patient with more than 1-year survival after treatment with voriconazole, despite invasive paranasal sinus aspergillosis involving the orbital apex.
CASE SUMMARY
A 74-year-old woman with only preexisting hypertension visited our clinic complaining of pain and immovable left eye that occurred approximately 4 days prior. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a sphenoid sinusitis with suspicious lesion involving the orbital apex of the left eye. A biopsy by functional endoscopic sphenoid surgery (FESS) was performed through the sphenoid sinus, which enabled us to diagnose aspergillosis. The patient had esotropia, ophthalmoplegia, positive RAPD, and ptosis in the left eye. On follow-up, a new MRI showed acute to subacute stage infarction at the left occipital lobe. After the patient was treated with intravenous voriconazole, ptosis, and ophthalmoplegia improved. At the 13-month follow-up, she was alive with no disease recurrence.
CONCLUSIONS
Invasive aspergillosis of orbit and cerebrum in healthy patients is a rare clinical entity. In case of central nervous system involvement, the survival outcome is poor with high mortality; however, good results can be obtained by treatment with voriconazole.

Keyword

Immunocompetent patient; Invasive aspergillosis; Orbital apex; Voriconazole

MeSH Terms

Aspergillosis
Biopsy
Central Nervous System
Cerebrum
Esotropia
Eye
Female
Follow-Up Studies
Humans
Hypertension
Infarction
Magnetic Resonance Imaging
Occipital Lobe
Ophthalmoplegia
Orbit
Pyrimidines
Sphenoid Sinus
Sphenoid Sinusitis
Triazoles
Pyrimidines
Triazoles

Figure

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  Figure 1. At the initial visit, the patient had 30 prism diopters of left esodeviation (E). There was limitation of elevation (A, B, C) and abduction (F) in the left eye.

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  Figure 2. Histologic finding (H&E stain ×400): Septated fungal hyphae with acute angle branching.

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  Figure 3. Magnetic resonance images (Axial view) showing invasive aspergillosis involving left ethmoid and sphenoid sinuses, left anterior clinoid process, left orbital apex with bony disruption, and lateral and superior wall of the left sphenoid sinus (A). Acute to subacute stage infarction, left occipital lobe (PCA territory) (B).

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  Figure 4. Magnetic resonance images (Axial view) showing invasive aspergillosis with slightly decreased fungal mass (A). Left occipital lobe (PCA territory) with hemorrhagic transformation in the cortex (B).

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  Figure 5. Computed tomographic scan (Axial cut) showing no significant abnormality of both orbits.

Reference

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