J Korean Ophthalmol Soc.  2015 Mar;56(3):471-476. 10.3341/jkos.2015.56.3.471.

A Case of the Third, Fourth, and Sixth Nerve Palsy in a Patient with Cerebral Aspergillosis

• Hwang SS
• Lee SJ

• KMID: 2339059
• DOI: http://doi.org/10.3341/jkos.2015.56.3.471

Abstract

PURPOSE
To report a case of cerebral aspergillosis with third, fourth, and sixth nerve palsy.
CASE SUMMARY
A 66-year-old female presented with ocular pain, diplopia, ptosis, and limited ocular movement of the right eye. The patient had experienced rhinorrhea and headache in the right temporal area 3 weeks prior and was treated with oral antibiotics for 1 week. Marginal reflex distance 1 was -4 mm in the right eye and +4 mm in the left eye. Upward, downward, medial, and lateral gaze limitation (-4/-4/-3.5/-2.5) was evaluated. Magnetic resonance imaging (MRI) revealed a mass originating from the nasopharynx and passing through the petrous apex, foramen lacerum, carvernous sinus, sphenoid sinus, orbital apex, and inferior orbital fissure. The mass had high signals on T2-weighted imaging. After 5 days, the mass was removed by endoscopic surgery and aspergillus was detected histopathologically. The patient was given intravenous voriconazole for 11 days and oral voriconazole for 11 weeks. Ptosis and ocular movement limitation began to improve after 6 weeks postoperatively. After 4 months, ocular movement was not limited and there was no recurrence during the 1 year follow-up period.
CONCLUSIONS
The present case showed that orbital aspergillosis can invade the intracranial area and third, fourth, and sixth nerve palsy can develop without exophthalmos. Thus, when ocular movement disorders, ptosis and symptoms of sinusitis are present in orbital aspergillosis patients, use of appropriate diagnostic tools such as MRI and active treatment are important.

Keyword

Cerebral aspergillosis; Nerve palsy; Orbital aspergillosis; Sinusitis; Voriconazole

MeSH Terms

Abducens Nerve Diseases*
Aged
Anti-Bacterial Agents
Aspergillosis*
Aspergillus
Diplopia
Exophthalmos
Female
Follow-Up Studies
Headache
Humans
Magnetic Resonance Imaging
Movement Disorders
Nasopharynx
Orbit
Recurrence
Reflex
Sinusitis
Sphenoid Sinus
Anti-Bacterial Agents

Figure

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  Figure 1. At the initial visit, the patient had ptosis of the right eye. However, there was no exophthalmos.

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  Figure 2. Nine cardinal gaze photographs show total ophthalmoplegia of the right eye.

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  Figure 3. (A) T1-weighted MR image revealed a mass in the right pterygopalatine fossa by low-signal intensity (arrow). (B) The lesion showed high-signal intensity in T2-weighted image (arrowhead).

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  Figure 4. (A) Gadolinium-en-hanced T1-weighted MR image revealed that the mass ex-tended to the right orbital apex and inferior portion of the optic canal with strong enhancement (arrow). (B) The axial view showed an invasion of the right cavernous sinus with peripheral enhancement (arrow- head).

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  Figure 5. Encasement of the petrous portion of the right internal carotid artery was shown in (A) T1-weighted sequence (arrow) and (B) T2-weighted sequence (arrow- head).

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  Figure 6. Histologic finding: (A) (PAS stain ×400): Septated fungal hyphae and (B) (GMS stain ×400): Invaded fungal hyphae into the necrotic tissue were found at middle turbinate tissue biopsy.

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  Figure 7. There was a complete resolution of ocular movement limitation at 4 months after surgery.

Reference

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