PMC3512341_01
Orbit MRI T1-weighted post-Gadolinium enhancement. (a, axial view) A small enhancing lesion about 1.2 cm x 1.1 cm x 1 cm noted near the right side orbital apex and adjacent right side superior orbital fissure with mild extension to the adjacent right side posterior ethmoid sinus region. (b, coronal view) This lesion had mild encasement of the right optic nerve
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F1
August 2010 with the chief complaint of decline of visual acuity of her right eye and right periorbital pain for 2 months. At the beginning of the clinical course, she had brain computed tomography (CT) scan and orbit magnetic resonance imaging (MRI) done in June 2010, which disclosed a small enhancing lesion, about 1.2 cm x 1.1 cm x 1 cm in size, near the right side orbital apex and adjacent right side superior orbital fissure with mild encasement of the right optic nerve, and this lesion showed mild extension to the adjacent right side posterior ethmoid sinus [Figure 1 a, b].
Repeated orbit MRI T1-weighted post-Gadolinium enhancement. (a) Axial view and (b) coronal view show the progression of the lesion
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F2
Repeated MRI of orbit after admission in August 2010 showed the progression of the lesion which enlarged up to 1.5 cm x 1.3 cm x 1.2 cm [Figure 2 a, b].
(a) Non-contrast brain CT demonstrated diffuse high-density acute subarachnoid hemorrhage in the basal cistern, pre-pontine cistern, ambient cistern, quadrigeminal cistern, cerebellomedullary cistern, and right sylvian fissure. (b) computed tomography angiography showed the presence of several bleb-like wide base aneurysms over right supraclinoid internal carotid artery. One aneurysm of about 4 mm showed extravasation of contrast medium. The dome of the ruptured aneurysm projected medially and superiorly
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F3
After endotracheal tube intubation and resuscitation, brain CT was checked which showed diffuse high-density acute SAH in the basal cistern, pre-pontine cistern, ambient cistern, quadrigeminal cistern, cerebellomedullary cistern, and right sylvian fissure, with acute hydrocephalus [Figure 3a]. The dome of the ruptured aneurysm projected medially and superiorly [Figure 3b].
Histology of the lesion. (a) H and E, x100. (b) PAS stain, x200. Both showed many fungal septate hyphae
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F4
On the same day, the histology examination reported that the lesion was composed of many fungal septate hyphae demonstrated on both HE stain and periodic acid-Schiff (PAS) stain [Figure 4a, b].