Journal List > J Korean Ophthalmol Soc > v.56(3) > 1010233

Hwang and Lee: A Case of the Third, Fourth, and Sixth Nerve Palsy in a Patient with Cerebral Aspergillosis

초록

Purpose:

To report a case of cerebral aspergillosis with third, fourth, and sixth nerve palsy.

Case summary:

A 66-year-old female presented with ocular pain, diplopia, ptosis, and limited ocular movement of the right eye. The patient had experienced rhinorrhea and headache in the right temporal area 3 weeks prior and was treated with oral anti-biotics for 1 week. Marginal reflex distance 1 was -4 mm in the right eye and +4 mm in the left eye. Upward, downward, medial, and lateral gaze limitation (-4/-4/-3.5/-2.5) was evaluated. Magnetic resonance imaging (MRI) revealed a mass originating from the nasopharynx and passing through the petrous apex, foramen lacerum, carvernous sinus, sphenoid sinus, orbital apex, and inferior orbital fissure. The mass had high signals on T2-weighted imaging. After 5 days, the mass was removed by endoscopic surgery and aspergillus was detected histopathologically. The patient was given intravenous voriconazole for 11 days and oral voriconazole for 11 weeks. Ptosis and ocular movement limitation began to improve after 6 weeks postoperatively. After 4 months, ocular movement was not limited and there was no recurrence during the 1 year follow-up period.

Conclusions:

The present case showed that orbital aspergillosis can invade the intracranial area and third, fourth, and sixth nerve palsy can develop without exophthalmos. Thus, when ocular movement disorders, ptosis and symptoms of sinusitis are present in orbital aspergillosis patients, use of appropriate diagnostic tools such as MRI and active treatment are important.

References

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Figure 1.
At the initial visit, the patient had ptosis of the right eye. However, there was no exophthalmos.
jkos-56-471f1.tif
Figure 2.
Nine cardinal gaze photographs show total ophthalmoplegia of the right eye.
jkos-56-471f2.tif
Figure 3.
(A) T1-weighted MR image revealed a mass in the right pterygopalatine fossa by low-signal intensity (arrow). (B) The lesion showed high-signal intensity in T2-weighted image (arrowhead).
jkos-56-471f3.tif
Figure 4.
(A) Gadolinium-en-hanced T1-weighted MR image revealed that the mass ex-tended to the right orbital apex and inferior portion of the optic canal with strong enhancement (arrow). (B) The axial view showed an invasion of the right cavernous sinus with peripheral enhancement (arrow- head).
jkos-56-471f4.tif
Figure 5.
Encasement of the petrous portion of the right internal carotid artery was shown in (A) T1-weighted sequence (arrow) and (B) T2-weighted sequence (arrow- head).
jkos-56-471f5.tif
Figure 6.
Histologic finding: (A) (PAS stain ×400): Septated fungal hyphae and (B) (GMS stain ×400): Invaded fungal hyphae into the necrotic tissue were found at middle turbinate tissue biopsy.
jkos-56-471f6.tif
Figure 7.
There was a complete resolution of ocular movement limitation at 4 months after surgery.
jkos-56-471f7.tif
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