An 86-year-old female with medical comorbidities including well-controlled type 2 diabetes (HbA1c 5.6 %) on oral therapy and glaucoma who presented with 2 weeks of right ear pain, right frontal headache and right facial pain just lateral to the nose. The patient also described painful extraocular movements (EOMs) on the right, decreased vision, and thick purulent drainage from the right nasal cavity. Vitals were normal with a blood pressure of 132/70, heart rate of 78, respiratory rate of 14, oxygen saturation of 97 % on room air, and temperature of 36.7 degrees Celsius. Examination was significant for hand motion vision, severely restricted right eye EOMs with ptosis, and excyclotorsion. Computerized tomography of the head and orbits demonstrated soft tissue thickening and indistinctness of fat in the region of the right optic canal and right orbital apex, possibly representing extension of paranasal inflammatory disease to an unusual bone defect in the right lateral wall of the right sphenoidal sinus (). Additionally, there was associated right anterior ethmoidal mucosal disease and complete opacification of the right maxillary antrum. Magnetic resonance imaging (MRI) of the brain without and with intravenous (IV) contrast showed right-sided paranasal sinus infection with transsphenoidal phlegmonous extension into the right orbital apex and cavernous sinus consistent with orbital apex syndrome (, ). Ophthalmology and otolaryngology (ENT) were consulted and performed a right endoscopy of the nasal cavities. This revealed purulence from the right middle meatus obstructing the view of the sphenoid. Nasal swab was sent for bacterial culture. Infectious disease was consulted who recommended IV vancomycin, cefepime, and metronidazole in addition to dexamethasone.\nThe patient underwent surgery on hospital day three. ENT completed a broad endoscopic sinus debridement including right total ethmoidectomy, frontal sinusotomy, sphenoidotomy, tissue biopsy, and washout of orbital apex with tissues sent for bacterial and fungal cultures. Tissue from the right naris and right ethmoid sinus grew methicillin-susceptible Staphylococcus aureus (MSSA). Initial pathology at frozen section examination revealed mixed acute and chronic inflammation at all biopsy sites. The patient’s antibiotics were narrowed to IV cefazolin on hospital day 5. On hospital day 6, one colony of Aspergillus fumigatus grew from a culture of the right orbital apex tissue. The pathology revealed fungal hyphae consistent with Aspergillus spp. and related molds, with tissue invasion in the orbital apex (, ). She was started on IV voriconazole. She was discharged to a skilled nursing facility after a 9-day hospital course with antimicrobials including oral cefdinir for a 4-week course and oral voriconazole with a planned treatment course of at least 12 weeks. At two-week follow-up with infectious disease, a repeat MRI brain showed worsening right ethmoid and sphenoid sinus fungal infection. Intravenous caspofungin was added to her regimen for a two-week course of therapy with clinical improvement. She underwent further debridement with rigid endoscopy at two, four, and six weeks after diagnosis with mostly crusted blood products and no evidence of necrotic tissue. Ophthalmologic exam ultimately demonstrated improvement in visual acuity to 20/50 with full EOMs.
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 ().