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 ().
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.