A case of cerebral infarction due to invasive sino-orbital aspergillosis

Abstract

A 72-year-old woman presented with pain and visual loss in the left eye, and diplopia. Computed tomography demonstrated a soft tissue shadow at the left side of the posterior ethmoid sinus, then she was diagnosed as sinusitis. Ethmoidectomy, as well as administration of antibiotics and steroids, once improved her symptoms, but visual loss recurred and gradually worsened with repeating the process of transient improving by the administration of antibiotics and steroids, resulting in the orbital apex syndrome. The serum data of β-D-glucan and Aspergillus antigen showed both negative. Thus far the nasal biopsy had been performed twice but Aspergillus was not detected. Initial steroid responsiveness suggested a possibility of granulomatosis with polyangiitis, thus cyclophosphamide additionally administered, but had no effect. Consciousness disturbance developed and magnetic resonance imaging revealed brainstem infarction. At this time, β-D-glucan and Aspergillus antigen level were elevated in the serum and cerebrospinal fluid, and the diagnosis of invasive aspergillosis was confirmed. Vascular invasion by Aspergillus advanced to cerebral infarction one after another, and caused her to death. In case of the sinusitis advancing to orbital apex syndrome, if the possibility of invasive aspergillosis cannot be excluded, careful measures should be taken such as administrating of antifungal agent and performing repetitive biopsies.