PMC4696048_01
(A-C) T1-weighted magnetic resonance image of the brain demonstrates a contrast enhancing mass along the left optic nerve extending into the ipsilateral sphenoid sinus and towards the left aspect of the chiasm. (D) Noncontrast computed tomography of the head demonstrates hypodense material in the left ethmoid and sphenoid sinuses with bony erosion, expansion of the ipsilateral optic canal, and sclerosis of the anterior clinoid process.
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F1
There was an associated expansion of the left optic canal with sclerosis of the anterior clinoid process and invasion of the adjacent sphenoid and ethmoid sinuses by the mass (Figure 1A-D).
(A) T1-weighted magnetic resonance imaging (MRI) of the brain demonstrates a new ring-enhancing, loculated, cavitary chiasmal lesion, contiguous with the mass seen on the patient's admission MRI scan with extension towards the right aspect of the optic chiasm and proximal origin of the right optic nerve. (B) Humphrey visual field test of the right eye demonstrates the acute temporal field defect noted by the patient. (C) Intraoperative view of the edematous left optic nerve (LON), right optic nerve (RON), and internal carotid artery (ICA).
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F2
A repeat MRI of the brain showed a new contrast-enhancing mass with a hypointense, loculated center, extending towards the right aspect of the chiasm and proximal right optic nerve (Figure 2A). Automated perimetry confirmed the visual field loss (Figure 2B). Intraoperatively, a chiasmal abscess extending to the proximal right optic nerve, corresponding to the new lesion on the MRI, was found (Figure 2C).
Photomicrograph of the surgical specimen stained with hematoxylin and eosin (A) and Grocott's methenamine silver (B) revealing findings of septate, acute-branching aspergillus hyphea. Periodic acid-Schiff (C) stain shows fungal forms (FF), tissue necrosis (TN), and optic nerve fibers (ONF).
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F3
Aspergillus fumigatus (Figure 3A-C). Antifungal therapy with intravenous voriconazole and micafungin was administered for 2 weeks with resolution of the enhancement within the right optic nerve and chiasm.
Postoperative T1-weighted magnetic resonance image of the brain demonstrates decreased enhancement of the remaining chiasm (A) corresponding to an improved right temporal visual field deficit (B).
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F4
His current imaging studies demonstrate no enhancement along the chiasm and right optic nerve (Figure 4A). His visual field has improved (Figure 4B), and his visual acuity remains stable.