PMC6381903_01
Ophthalmic examination findings. Fundus photograph (a) and GP (b) of the left eye at initial onset. The optic disc was reddish and mildly swollen. GP showed lower horizontal hemianopia. Fundus photograph of the right eye (c) and the left eye (d), fluorescein angiography of the right eye (e) and left eye (f), and GP of the right eye (g) with onset in the right eye. The optic disc was reddish and mildly swollen with splinter hemorrhage, and the optic disc of the left eye was markedly swollen with mild retinal hemorrhage. Hyperfluorescence in the left eye was much more intense than in the right eye. Delay of choroidal circulation was detected in the lower retina (arrowheads). Time after initiation of the right eye and left eye was 113 and 65 s, respectively.
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F1
Fundus examination showed optic disc swelling of the left eye (Fig. 1a). Goldmann perimetry (GP) revealed lower altitudinal hemianopia in the left eye (Fig. 1b). Two months later, BCVA in the right eye also decreased to 0.5, the right optic disc began to swell, and swelling of the left optic disc persisted and became more severe (Fig. 1c, d). Fluorescein angiography exhibited marked hyperfluorescence of the optic disc with filling defect in the choroidal circulation in the left eye and slight hyperfluorescence of the optic disc in the right eye (Fig. 1e, f). GP in the right eye showed irregular visual defect in both the superior and inferior visual field (Fig. 1g).
Brain MRI STIR image (a) at the initial onset when the left eye was affected, T1WI (WI) at the onset when the right eye was affected (b), and STIR image at the onset when the right eye was affected (c). There was no the apparent swelling or high-intensity area in the optic nerve at the occurrence of disc swelling in both eyes. d T2WI of the brain at the time when the patient was febrile with depressed consciousness; e DWI; f ADC map. There was a high-intensity area around the cerebral aqueduct in the midbrain on T2WI, representing a high-intensity area on DWI and a low-intensity area on the ADC map (arrows in d-f). DWI, diffusion-weighted imaging; ADC, apparent diffusion coefficient.
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F2
T2-weighted imaging (T2WI) and short-T1 inversion recovery (STIR) showed no optic nerve or paranasal sinus abnormalities without gadolinium (Gd) enhancement due to renal dysfunction (Fig. 2a, b). Thus, the previous ophthalmologist suspected her as having anterior ischemic optic neuropathy and administered mini-pulse steroid therapy and 500 mg methylprednisolone to relieve the disc swelling. MRI of the brain and orbits revealed no obvious optic nerve swelling without any apparent parenchymal hyperintensity on STIR images (Fig. 2c). On the same day, repeat MRI showed suspected midbrain infarction (Fig. 2d-f), and CSF findings indicated cerebral meningitis (cells 303/muL, proteins 63 mg/dL, glucose 89 mg/dL, and negative cryptococcal antigen).
Microphotograph of optic nerve sections. The transverse section of the optic nerve was stained with H&E (a low magnification image, b high magnification image). c, d The transverse section of the optic nerve stained with PAS. Scale bar indicates 500 microm in a and c and 100 microm in b and d. A large amount of PAS-positive A. hyphae and inflammatory cells densely accumulated in the dura mater (arrowheads). PAS, periodic acid-Schiff.
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F3
Histological examination showed a significant amount of Aspergillus hyphae, inflammatory cells, and fibrous formation mainly localized in the dura mater, whereas cellular infiltration into the parenchyma of the optic nerve was less observed (Fig. 3a-d).