A 69-year-old male was admitted with a progressive frontal paroxysmal headache accompanied with mild vomiting, diplopia, and visual disturbance for 1 month, without fever. Visual acuity was 0.6 in the left eye and 0.9 in the right eye without visual field loss. Other neurologic and clinical findings were normal. He was healthy other than a 10-year history of well-controlled hypertension and coronary heart disease. The patient reported no history of fungal infection or a history of contact with unusual infectious sources. CT scan showed a mass in the sphenoid sinus and clival region. Bone destruction was observed in both regions (Fig. a). MRI showed a hypointense signal on T2-weighted images (T2WI) in the lesions and an isointense signal on T1 weighted images (T2WI) with heterogeneous gadolinium-enhancement in the sphenoid sinus, both cavernous sinuses, bilateral ethmoid sinuses, and maxillary sinus (Fig. b–d). This patient underwent trans-sphenoidal lesion debridement. Purulence was observed during the operation. A biopsy was performed immediately and histopathology examination revealed Aspergillus species (Fig. e). The patient was administered fluconazole after surgery. Post-operative neurological examination showed obvious improvement of headache, vomiting, vision, and diplopia. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up period of 24 months showed no clinical symptoms, and no additional therapy was required.
A 64-year-old male had experienced a paroxysmal pain in the frontal region and left nose radiating to the occipital region for 7 months. The patient also reported progressive paresthesia on the left cheek and rapidly decreasing visual acuity in the left eye. Neurological examination revealed a left-sided ptosis as the only new finding. Interestingly, body temperature (axillary) fluctuated between 36.1 °C and 38.4 °C. The patient denied a history of other diseases. Physical examination showed no light perception or reflex was detected in the left eye. His pupils were 3 mm on the right and 4 mm on the left. CT showed an isodense lesion in the region of the left cavernous sinus, left orbital apex, left optic nerve canal, and sphenoid sinus. Bone destruction was seen in the left wall of the sphenoid sinus (Fig. a). MRI showed a 33 × 16 mm isointense lesion in both T1WI and T2WI of the left optic canal region and extending into the orbit. Enhanced-MRI showed ring enhancement of the lesion. Lesions with hyperintense T2-weighted signal were seen in paranasal sinuses (Fig. b–d). The patient was self-treated with anti-infectious medication but his headache increased in intensity, frequency, and duration. The patient underwent mass excision of the mass via pterional craniotomy. Cream-like liquid amidst a gray growth was observed in the left cavernous sinus. A biopsy was performed immediately, and histopathologic examination revealed an Aspergillus species (Fig. e). Post-operative images indicated the resection of mass (Fig. f). The patient received voriconazole after surgery. However, he was lost to follow-up.