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Department of Emergency Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung 40705, TaiwanSchool of Medicine, Chung Shan Medical University, Taichung, TaiwanInstitute of Medicine, Chung Shan Medical University, Taichung, TaiwanDepartment of Nursing, College of Health, National Taichung University of Science and Technology, Taichung, Taiwan
Radiologic studies to exclude mass or vascular lesion, including computed tomography and magnetic resonance imaging, should be mandatory in patients of oculomotor palsy.
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It is necessary to identify the etiology of intracranial foci through the histopathology and culture of tissue biopsy.
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Full-course antifungal drugs should be prescribed in patients of invasive aspergillosis with surgical resection for focal lesion
Graphical abstract
The patient was a 70-year-old diabetic Taiwanese woman, with a past medical history of otitis media status post surgery performed 2 years prior. She presented to the emergency department with a progression of headache, double vision, and ptosis of the right eye occurring over the course of 1 month, following an inability to perform lateral gaze. A neurological examination demonstrated palsy of intracranial nerves III, IV, and IV of the right eye. A computed tomography scan and magnetic resonance imaging of the brain showed abnormal contrast enhancement of the right maxillary sinus, cavernous sinus, and superior orbital apex, along with skull base bony destruction (Figure 1A) . A biopsy of the right paranasal sinus was performed by endoscopic sinus surgery, and photomicrographs revealed a fungal ball with numerous characteristic septate fungal hyphae of an Aspergillus species and hyphae branched dichotomously at a 45-degree angle (Figure 1B). Treatment with intravenous amphotericin B (50 mg daily) was prescribed for 1 week; this was then changed to voriconazole (200 mg twice daily) for 6 months, in the outpatient department.
Figure 1A Contrast-enhanced computed tomography scan of the brain demonstrating abnormal contrast enhancement of the maxillary sinus, cavernous sinus, and superior orbital apex on the axial image (red arrow). Axial T2-weighted contrast-enhanced magnetic resonance imaging of the brain showing abnormal contrast enhancement of the maxillary sinus, cavernous sinus, and superior orbital apex, with skull base bony destruction (red–white arrow). (B) Photomicrograph revealing a fungal ball with numerous branching hyphae (hematoxylin–eosin stain, ×100, red arrow) and characteristic septate fungal hyphae of an Aspergillus species, and hyphae branching dichotomously at a 45-degree angle (hematoxylin–eosin stain, ×400, red–white arrow).
High incidences of invasive fungal infections in acute myeloid leukemia patients receiving induction chemotherapy without systemic antifungal prophylaxis: a prospective observational study in Taiwan.
Invasive aspergillosis of the intracranial nerve system is a difficult diagnostic challenge and has a high mortality rate, especially in those in an immunocompromised condition. Sinusitis, vascular narrowing or obstruction, and bony destruction are radiological signs of invasive fungal infection. A definite diagnosis of aspergillosis is based on the histopathological characteristics of the tissue involved demonstrating a fungal ball with aggregates of spores and hyphae with 45-degree branching.
Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Consent: Written informed consent was obtained from the patient for publication of this case report and all accompanying images.
Conflict of interest: No competing interest declared.
References
Tang J.L.
Kung H.C.
Lei W.C.
Yao M.
Wu U.I.
Hsu S.C.
et al.
High incidences of invasive fungal infections in acute myeloid leukemia patients receiving induction chemotherapy without systemic antifungal prophylaxis: a prospective observational study in Taiwan.
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