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 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 ().