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Journal of Neuro-Ophthalmology:
doi: 10.1097/WNO.0b013e3181772e90
Letters to the Editor

Transient Third Cranial Nerve Palsy Caused by Sphenoid Sinus Aspergillosis

Tsai, Rong Kung MD; He, Ming Shan MD; Cheu, Chung Lung MD; Sheu, Min Muh MD

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Department of Ophthalmology Buddhist Tzu Chi General Hospital Tzu Chi University Hualien, Taiwan rktsai@tzuchi.com.tw

Department of Neurosurgery Buddhist Tzu Chi General Hospital Tzu Chi University Hualien, Taiwan

Department of Ophthalmology Buddhist Tzu Chi General Hospital Tzu Chi University Hualien, Taiwan

We recently examined a patient who developed a nearly complete unilateral third cranial nerve palsy attributed to sphenoid sinus aspergillosis. The unusual feature is that the palsy resolved spontaneously within 2 days.

A 78-year-old retired teacher presented with the sudden onset of a ptotic right upper lid and diplopia for 1 day. There was no headache. He had hypertension and chronic renal impairment but no diabetes or head trauma.

Vital signs were normal. Visual acuity was 20/40 in both eyes attributed to cataract. Intraocular pressures were 12 mm Hg in both eyes. In dim light, pupils measured 4.5 mm in the right eye and 3 mm in the left eye. The right pupil was not reactive to light; the left pupil was normally reactive. There was no afferent pupil defect. There was complete right upper lid ptosis and a complete deficit of adduction, supraduction, and infraduction of the right eye with normal incyclotorsion and abduction. Ductions of the left eye were normal. Findings from ophthalmoscopy and the rest of the neurological examination were normal.

Although we recommended emergency neuroimaging, the patient insisted on later admission for personal reasons. Two days later, our examination showed complete resolution of all eye findings, but he reported brief episodes of syncope, mental confusion, and headache.

Complete blood count showed a mild leukocytosis (10.6 103 cells/μL), and C-reactive protein was 1.37 mg/dL. Erythrocyte sedimentation rate was 35 mm/hr. Brain MRI showed a heterogeneous space-occupying lesion in the right sphenoid sinus and a soft tissue lesion in the basal cisterns and sylvian fissure with low signal intensity on precontrast T1 and enhancement on postcontrast T1. There were also a subdural effusion (Fig. 1). MRA demonstrated no aneurysm.

Fig. 1
Fig. 1
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Transsphenoidal endoscopic biopsy disclosed necrotic tissue with a pathologic diagnosis of aspergillosis (Fig. 2). The patient was given intravenous voriconazole for 3 weeks followed by oral fluconazole. Neurologic symptoms and the original MRI lesions eventually resolved (Fig. 1C).

Fig. 2
Fig. 2
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Transient third cranial nerve palsy occurs in ophthalmoplegic migraine (1,2), pseudotumor cerebri (3,4), arteriovenous malformation (5), cryptococcal meningitis (6,7), basilar or posterior communicating artery aneurysm (8,9), and thiazide-induced glucose intolerance (10). It has not been reported in sphenoid sinus aspergillosis.

The transient nature of our patient's third cranial nerve palsy is curious. A possible explanation is that the nerve was initially compressed by localized sphenoid inflammation; perhaps as the pathogen broke through the sphenoid bone and invaded the contiguous basal cistern, the tension of compression was released, allowing spontaneous resolution of the palsy but development of other neurologic deficits.

Rong Kung Tsai, MD

Department of Ophthalmology

Buddhist Tzu Chi General Hospital

Tzu Chi University

Hualien, Taiwan

rktsai@tzuchi.com.tw

Ming Shan He, MD

Department of Ophthalmology

Buddhist Tzu Chi General Hospital

Tzu Chi University

Hualien, Taiwan

Chung Lung Cheu, MD

Department of Neurosurgery

Buddhist Tzu Chi General Hospital

Tzu Chi University

Hualien, Taiwan

Min Muh Sheu, MD

Department of Ophthalmology

Buddhist Tzu Chi General Hospital

Tzu Chi University

Hualien, Taiwan

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REFERENCES

1. McMillan HJ, Keene DL, Jacob P, et al. Ophthalmoplegic migraine: inflammatory neuropathy with secondary migraine? Can J Neurol Sci 2007;34:349-55.

2. Levin M, Ward TN. Ophthalmoplegic migraine. Curr Pain Headache Rep 2004;8:306-9.

3. McCammon A, Kaufman HH, Sears ES. Transient oculomotor paralysis in pseudotumor cerebri. Neurology 1981;31:182-4.

4. Chansoria M, Agrawal A, Ganghoriya P, et al. Pseudotumor cerebri with transient oculomotor palsy. Indian J Pediatr 2005;72:1047-8.

5. Wu G, Agrawal A, Ghanchi FD. Transient third nerve palsy in a young patient with intracranial arteriovenous malformation. Eur J Ophthalmol 2003;13:324-7.

6. Keane JR. Intermittent third nerve palsy with cryptococcal meningitis. J Clin Neuroophthalmol 1993;13:124-6.

7. Azran MS, Waljee A, Biousse V, et al. Episodic third nerve palsy with cryptococcal meningitis. Neurology 2005;64:759-60.

8. DiMario FJ Jr, Rorke LB. Transient oculomotor nerve paresis in congenital distal basilar artery aneurysm. Pediatr Neurol 1992;8:303-6.

9. Greenspan BN, Reeves AG,. Transient partial oculomotor nerve paresis with posterior communicating artery aneurysm: a case report. J Clin Neuroophthalmol 1990;10:56-8.

10. Miller NR, Moses H. Transient oculomotor nerve palsy: association with thiazide-induced glucose intolerance. JAMA 1978;240:1887-8.

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