The Difficulty of Diagnosing Invasive Aspergillosis Initially Manifesting as Optic Neuropathy
The Difficulty of Diagnosing Invasive Aspergillosis Initially Manifesting as Optic Neuropathy
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DOI：
10.1159/000495979
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发表时间：
2019-01
影响因子：
0.4
通讯作者：
Sotaro Mori;Takuji Kurimoto;Kana Kawara;Kaori Ueda;Mari Sakamoto;Yukako Keshi;Yuko Yamada-Nakanishi;Hisatsugu Tachibana;Makoto Nakamura
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作者：
Sotaro Mori;Takuji Kurimoto;Kana Kawara;Kaori Ueda;Mari Sakamoto;Yukako Keshi;Yuko Yamada-Nakanishi;Hisatsugu Tachibana;Makoto Nakamura
背景：侵袭性曲霉菌病通常是致命的。在这里，我们报告一个病人的侵袭性曲霉菌病主要涉及视神经尸检诊断。案例介绍：一位77岁女性，患有糖尿病、高脂血症和高血压，左眼视盘肿胀。虽然小脉冲类固醇治疗改善了左眼的视敏度（VA），但在一个月内突然下降至无光感，随后右眼的VA下降至0.5。转诊时，右眼视力为0.3，左眼无光感。结果：眼底检查发现双眼视盘肿胀。Goldmann视野检查显示不规则视野缺损，而磁共振成像（MRI）、全身和脑脊液（CSF）检查未发现明显异常。我们怀疑前部缺血性视神经病变和侵袭性视神经病变。与左眼一样，类固醇脉冲治疗暂时改善了右眼的VA，然后降至0.2。额外的抗凝治疗没有改善VA。在治疗的同时，患者发热伴意识抑郁。重复MRI发现疑似中脑梗死，CSF检查提示脑膜炎。尽管给予输血和抗生素治疗，她还是在住院第40天死亡。尸检发现大量曲霉菌菌丝主要位于视神经的硬脑膜和脑动脉壁的破坏，提示蛛网膜下腔出血的病因。结论：当检查顽固性和持续性椎间盘肿胀时，我们应该排除视神经真菌感染。
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.