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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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Journal of Neuro-Ophthalmology: September 2008 - Volume 28 - Issue 3 - p 239-240
doi: 10.1097/WNO.0b013e3181772e90
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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.

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. 1
FIG. 1:
Pretreatment postcontrast TI axial (A) and coronal (B) MRI shows enhancing soft tissue lesions with low central signal intensity in both sylvian fissures, the prepontine cistern, and the right sphenoid sinus (A, arrow). One month after systemic antifungal treatment, postcontrast T1 MRI (C) demonstrates mucosal thickening with enhancement of the sphenoid sinus mucosa (arrow) and dural enhancement with nodularity (arrowhead).
FIG. 2
FIG. 2:
1887-8. Histopathology of the sphenoid sinus tissue shows aggregates of 45° branching hyphae with septae (inset, arrowhead) that are 2-4 mm in width, features characteristic of aspergillosis (hematoxylin and eosin stain, original magnification: ×400).

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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