A 52-year-old male was admitted with a paroxysmal headache in the right parietal region accompanied by visual disturbance in the right eye for over 2 months. Both symptoms mostly occurred in the morning and could be partially relieved with ibuprofen. He had a 2-year history of diabetes mellitus type 2 well controlled with metformin and repaglinide. He was afebrile and neurological examination was unremarkable. CT scan showed a mass in sphenoid sinus and cavernous sinus with bone destruction (Fig. a). MRI showed a 20 × 25 mm circular intrasellar mass with hyperintensity T1WI and T2WI, heterogeneously gadolinium-enhancement, and adjacent meningeal enhancement. The lesion extended bilaterally into the cavernous sinus and formed a 12 × 11 mm mass (Fig. b–d). The patient underwent a trans-sphenoidal mass excision and debridement. The lesion was solid and cystic with yellow-brown fluid and a gray wax-like solid component. A biopsy was performed immediately and histopathologic examination revealed Aspergillus species (Fig. e). Post-operative physical and neurological examination showed obvious improvement of headache and visual disturbance. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up of 20 months showed no clinical symptoms.
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.