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

Abstract

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 antibiotics 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. J Korean Ophthalmol Soc 2015;56(3):471-476