Invasive Aspergillosis Mimicking Sphenoid Wing Meningioma

We read with interest the recent articles by Hersh et al (1) on 'Optic neuropathy and stroke secondary to invasive aspergillosis in an immunocompetent patient' and by Zhou et al (2) on 'Apical orbital aspergillosis complicating giant cell arteritis.' We present a case of invasive aspergillosis, in which the diagnosis was delayed because of a protracted clinical course and neuroimaging findings suggestive of a sphenoid wing meningioma.

Letters to the Editor 8. MacDonald JR. Potential causes, mechanisms, and implications of post exercise hypotension. J Hum Hypertens. 2002;16:225–236. 9. Pomeranz HD, Smith KH, Hart WM, Egan RA. Sildenafilassociated nonarteritic anterior ischemic optic neuropathy. Ophthalmology. 2002;109:584–587. 10. Pomeranz HD, Bhavsar AR. Nonarteritic ischemic optic neuropathy developing soon after use of sildenafil (viagra): a report of seven new cases. J Neuroophthalmol. 2005;25:9–13. 11. Tarantini A, Faraoni A, Menchini F, Lanzetta P. Bilateral simultaneous nonarteritic anterior ischemic optic neuropathy after ingestion of sildenafil for erectile dysfunction. Case Rep Med. 2012;2012:747658. 12. Bollinger K, Lee MS. Recurrent visual field defect and ischemic optic neuropathy associated with tadalafil rechallenge. Arch Ophthalmol. 2005;123:400–401. 13. Egan R, Pomeranz H. Sildenafil (Viagra) associated anterior ischemic optic neuropathy. Arch Ophthalmol. 2000;118: 291–292. 14. Cunningham AV, Smith KH. Anterior ischemic optic neuropathy associated with viagra. J Neuroophthalmol. 2001;21:22–25. 15. Dheer S, Rekhi GS, Merlyn S. Sildenafil associated anterior ischaemic optic neuropathy. J Assoc Physicians India. 2002;50:265. 16. Pepin S, Pitha-Rowe I. Stepwise decline in visual field after serial sildenafil use. J Neuroophthalmol. 2008;28:76–77. 17. Gaffuri M, Cristofaletti A, Mansoldo C, Biban P. Acute onset of bilateral visual loss during sildenafil therapy in a young infant with congenital heart disease. BMJ Case Rep. 2014;2014. 18. Sivaswamy L, Vanstavern GP. Ischemic optic neuropathy in a child. Pediatr Neurol. 2007;37:371–372. Invasive Aspergillosis Mimicking Sphenoid Wing Meningioma nerve were performed. Permanent sections demonstrated dense plasmacytic infiltrates, scattered regions of necrosis, and hyphae with positive Gomori methenamine silver staining and positive immunostaining for Aspergillus (Fig. 2). The patient was begun on amphotericin and posaconazole and then switched to voriconazole for long-term treatment of invasive aspergillosis. He underwent an unremarkable immune workup, including testing negative for HIV. Our case underscores that aspergillosis is a great mimicker, with highly variable neuroimaging patterns, and biopsy should be strongly considered in any case of presumed meningioma with atypical features such as vascular occlusion. Cavernous sinus meningioma is known to infiltrate or encase the wall of the internal carotid artery, but vascular occlusion is not a typical W e read with interest the recent articles by Hersh et al (1) on “Optic neuropathy and stroke secondary to invasive aspergillosis in an immunocompetent patient” and by Zhou et al (2) on “Apical orbital aspergillosis complicating giant cell arteritis.” We present a case of invasive aspergillosis, in which the diagnosis was delayed because of a protracted clinical course and neuroimaging findings suggestive of a sphenoid wing meningioma. A 68-year-old man from Nicaragua, with well-controlled hypertension and diabetes mellitus, was evaluated for a 1-year history of right-sided headaches, followed by diplopia, and sudden vision loss in his right eye. Brain computed tomography (CT) and cerebral angiography performed in Central America revealed a sphenoid wing and cavernous sinus lesion, suspected to be a meningioma, as well as occlusion of the right internal carotid artery. After neurosurgical evaluation, the patient was offered the option of pursuing radiation therapy for meningioma and traveled to the United States for radiation oncology evaluation. On our examination, vision was no light perception, right eye, and 20/40, left eye with an amaurotic right pupil. The right eye had complete ptosis and ophthalmoplegia, and there was decreased facial sensation in the distribution of the ophthalmic division of the right trigeminal nerve. Brain MRI demonstrated an abnormality along the right sphenoid wing with involvement of the right cavernous sinus and orbital apex (Fig. 1). The patient underwent a right pterional craniotomy, with frozen sections showing fungal hyphae. Exenteration of the right cavernous sinus, removal of the anterior and posterior clinoid processes, and excision of involved segments of the thrombosed right cavernous carotid artery and right optic Letters to the Editor: J Neuro-Ophthalmol 2017; 37: 104-109 FIG. 1. Postcontrast axial T1 MRI shows a right sphenoid wing lesion (arrows) with involvement of the right cavernous sinus and orbital apex. 105 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Letters to the Editor FIG. 2. Biopsy specimens demonstrate fungal elements with acute-angle branching septate hyphae, typical of Aspergillus. A. (hematoxylin and eosin, ·400). B. (Gomori methenamine silver, ·400). C. (immunostain for Aspergillus, ·400). characteristic of this neoplasm (3). In contrast, vascular damage and thrombosis are hallmarks of fungal infection including Aspergillus (1,4,5). Of interest, our patient had MRI characteristics suggestive of meningioma, including isointensity on noncontrasted T1-and T2-sequences with homogeneous gadolinium enhancement and vasogenic edema (6). This, in part, led to a delay in establishing the correct diagnosis. Amanda D. Henderson, MD Division of Neuro-Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida Division of Neuro-Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland Jacques J. Morcos, MD Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, Florida Oliver G. Fischer, MD, MS Division of Ocular Pathology, Bascom Palmer Eye Institute, Miami, Florida Nonarteritic Ischemic Optic Neuropathy Associated With Clomiphene Citrate Use W e read with great interest the 14th Hoyt Lecture by Arnold (1) dealing with ischemic optic neuropathy. In particular, we were drawn to the discussion of systemic 106 Department of Ophthalmology, Bassett Healthcare Network, Cooperstown, New York Byron L. Lam, MD Joshua Pasol, MD Division of Neuro-Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida The authors report no conflicts of interest. REFERENCES 1. Hersh CM, John S, Subei A, Willis MA, Kosmorsky GS, Prayson RA, Bhimraj A. Optic neuropathy and stroke secondary to invasive Aspergillus in an immunocompetent patient. J Neuroophthalmol. 2016;36:1–4. 2. Zhou Y, Morgan ML, Almarzouqi SJ, Chevez-Barrios P, Lee AG. Apical orbital aspergillosis complicating giant cell arteritis. J Neuroophthalmol. 2016;36:159–163. 3. Kotapka MJ, Kalia KK, Martinez AJ, Sekhar LN. Infiltration of the carotid artery by cavernous sinus meningioma. J Neurosurg. 1994;81:252–255. 4. Shamim MS, Siddiqui AA, Enam SA, Shah AA, Jooma R, Anwar S. Craniocerebral aspergillosis in immunocompetent hosts: surgical perspective. Neurol India. 2007;55: 274–281. 5. Nadkarni T, Goel A. Aspergilloma of the brain: an overview. J Postgrad Med. 2005;51:S37–S41. 6. Saloner D, Uzelac A, Hetts S, Martin A, Dillon W. Modern meningioma imaging techniques. J Neurooncol. 2010;99:333–340. risk factors and the potential role that medications play in pathogenesis of nonarteritic ischemic optic neuropathy (NAION). We present a case of NAION related to a medication that should be included in the list of risk factors. A 35-year-old man complained of the acute onset of an inferonasal scotoma in his left visual field. He had no significant medical history, including diabetes mellitus, Letters to the Editor: J Neuro-Ophthalmol 2017; 37: 104-109 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.