PMC4180649_01
Photograph showing left sided partial ptosis and enophthalmos with wasting of hypothenar eminence of left hand.
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Examination of eye revealed left sided Horner's syndrome only, that is, presence of partial ptosis, enophthalmos, miosis, in association with anhidrosis over the left hemifacial region, and loss of ciliospinal reflex with preservation of pupillary light reflex and corneal reflex on the same side (Figure 1). Examination of left superior extremity revealed only the weakness of small muscles of the left hand (grade III power) and wasting of hypothenar eminence on left side (Figure 1).
CECT thorax showing heterogeneous, pleural based lung masses in upper lobes of both sides.
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Contrast enhanced computed tomography (CECT) scan of thorax showed two ill-defined, heterogeneous, mildly enhanced, partly necrotic, pleural based lesions in the apicoposterior segments of both upper lobes (Figure 2).
Microphotograph of histopathological examination of CT-guided tru-cut biopsy showing branching filamentous fungi with septate hyphae with finger-like branching at acute angles (lactophenol cotton blue stain, 40x).
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fig3
Finally, CT-guided tru-cut biopsy tissue taken from the lesions of both sides showed branching filamentous fungi with septate hyphae branching at acute angles (lactophenol cotton blue stain), suggestive of bilateral fungal abscesses in upper lobes, out of which the left one resulted in Pancoast's syndrome (Figure 3). Finally, fungal culture of biopsy tissue showed growth of fungus with septate hyphae having finger-like branching at acute angles, suggestive of growth of Aspergillus fumigatus.
CXR-P.A. views showing pretreatment bilateral apical consolidations with necrosis (a) and posttreatment almost complete resolution of the lesions (b).
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fig4
Six weeks of treatment with oral antifungals resulted in radiological resolution of both apical lesions (Figure 4), along with clinical recovery of left sided Pancoast's syndrome and Horner's syndrome, documented on followup.