The Difficulty of Diagnosing Invasive Aspergillosis Initially Manifesting as Optic Neuropathy

• Main Authors: Sotaro Mori, Takuji Kurimoto, Kana Kawara, Kaori Ueda, Mari Sakamoto, Yukako Keshi, Yuko Yamada-Nakanishi, Hisatsugu Tachibana, Makoto Nakamura
• Format: Article
• Language: English
• Published: Karger Publishers 2019-01-01
• Series: Case Reports in Ophthalmology
• Subjects: Invasive aspergillosis; Optic neuropathy; Autopsy; Steroid pulse therapy; Fungal infections
• Online Access: https://www.karger.com/Article/FullText/495979

Background: Invasive aspergillosis is often fatal. Here, we report a patient with invasive aspergillosis primarily involving the optic nerve diagnosed on autopsy. Case Presentation: A 77-year-old female with underlying diabetes mellitus, hyperlipidemia, and hypertension presented with disc swelling of the left eye. Although mini-pulse steroid therapy improved visual acuity (VA) of the left eye, it abruptly decreased to no light perception within a month, followed by a decrease in VA of the right eye to 0.5. At referral, VA was 0.3 in the right eye, and there was no light perception in the left eye. Results: Fundus examination revealed optic disc swelling of both eyes. Goldmann perimetry showed irregular visual field defects, whereas magnetic resonance imaging (MRI), general, and cerebrospinal fluid (CSF) examinations revealed no distinct abnormalities. We suspected anterior ischemic optic neuropathy and invasive optic neuropathy. As with the left eye, steroid pulse therapy temporarily improved VA of the right eye and then decreased to 0.2. Additional anticoagulant therapy did not improve VA. Concurrent to therapy, the patient became febrile with depressed consciousness. Repeat MRI identified suspected midbrain infarction, and CSF examination indicated cerebral meningitis. In spite of administering transfusions and antibiotics, she died on hospital day 40. Autopsy revealed large amounts of Aspergillus hyphae mainly localized in the dura mater of the optic nerve and destruction of the cerebral artery wall, suggesting an etiology of subarachnoid hemorrhage. Conclusions: When examining refractory and persistent disc swelling, we should rule out fungal infections of the optic nerve.