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 73-year-old male was admitted to our hospital with the complaints of headache persisting for approximately three months, and presented with progressive visual deterioration and ptosis in the right eye. He had no known disease and no apparent immune deficiencies. On physical examination, he was afebrile, but he had experienced unintentional weight loss and fatigue. His general condition was poor as a result of malnutrition. The neurological examination revealed a ptosis, ophthalmoplegia, and impairment of visual acuity on the right eye. His laboratory results were as follows : white cell count, 9.100/µL; sedimentation rate, C-reactive protein, peripheral smear and biochemical tests were all in normal range. Viral markers were negative.\nMagnetic resonance imaging (MRI) revealed a mass in the right cavernous sinus, extended to the anterior crainial fossa and the superior orbital fissure with an iso-signal intensity in T1-weighted iamge. The lesion showed a slightly low signal intensity in T2-weighted sequences and strong enhancement (). Based on these MRI findings, the impression was inflammatory abscess, but meningioma or metastatic tumor were also suspected. The patient underwent a pterional approach craniotomy for pathologic diagnosis and decompression of neural structures. During surgery, a well-encapsulated pus pocket was found at the clinoid process, and severe adhesion with the surrounding tissue was encountered. An intra-operative frozen biopsy revealed a fungal infection. The biopsy material showed inflammatory granulation tissue and micro abscesses containing a large number of hyphae with 45 degree angulations and spores (). The pathology result was consistent with aspergillus infection.\nPostoperatively, the patient was treated by systemic administration of antifungal drug (Amphotericin-B and Voriconazole), to which he showed only a minimal response. Despite appropriate medical and surgical treatment, the disease progressed and the patient eventually died from fatal cerebral ischemic change and severe brain swelling on the 23rd postoperative day ().