Masquerade - Video

The patient underwent right pterional craniotomy with removal of the sphenoid lesion, dura, and an intraparenchymal component. Frozen specimens showed fungal hyphae concerning for mucormycosis. For that reason, he underwent exenteration of the right cavernous sinus, right cavernous carotid, and right optic nerve, and removal of the anterior and posterior clinoid processes. The procedure included complex skull base reconstruction with right abdominal fat graft. The globe itself was not violated. Therapy with amphotericin B and posaconazole was initiated. Postoperative ocular examination demonstrated no light perception in the right eye and 20/40-2 in the left eye. The right pupil was fixed and dilated with a large afferent pupillary defect by reverse. There was slight temporal constriction of the visual field in the left eye by confrontation. The right eye had complete ptosis and ophthalmoplegia, and the external appearance of the left eye was normal with full extraocular movements. Despite the preliminary pathologic diagnosis of mucormycosis, permanent sections demonstrated dense plasmacytic infiltrates, scattered regions of necrosis, and hyphae with positive GMS-staining and positive immunostaining for Aspergillus. The patient completed a course of amphotericin and was switched from posaconazole to voriconazole for long-term treatment of invasive aspergillosis.