{
  "abstract": "Backgrond Angioinvasive aspergillosis is an aggressive, life-threatening fungal infection. Leptomeningeal dissemination and brainstem involvement can mimic inflammatory disorders, making diagnosis challenging.Case A 76-year-old man with type 2 diabetes and a history of septoplasty presented with painless binocular vertical diplopia and a frontal headache. Examination revealed left cranial nerve 4 palsy with normal visual acuity, without other cranial nerve or brainstem signs. Initial MRI showed no infective, inflammatory, or demyelinating lesions. Temporal artery biopsy and serum testing ruled out giant cell arteritis and vasculitis. He was empirically treated with methylprednisolone for a presumed inflammatory cause.He later developed left frontal sinus pain and ophthalmoplegia involving cranial nerves 3, 4, and 6, with visual acuity decline to 6/60. CSF and serum analysis excluded multiple sclerosis, neuromyelitis optica, and MOG antibody disease. CSF WCC was elevated at 27, but no organisms grew. Methylprednisolone was stopped. Nasoendoscopy biopsy did not confirm infection or IgG4 disease. Repeat MRI revealed severe left ICA narrowing. Despite voriconazole, his condition worsened with complete right ophthalmoplegia, sepsis, and death. Post-mortem brain biopsy confirmed fungal hyphae in leptomeningeal and brainstem vasculature, consistent with aspergillosis.Conclusion Angioinvasive aspergillosis can present with cranial neuropathies due to brainstem leptomeningeal involvement. Though common in immunocompromised patients, it may be elusive. A high index of suspicion is needed when inflammatory causes are excluded. Serial vascular imaging may help identify rapid arterial narrowing as a diagnostic clue.",
  "authors": [
    {
      "affiliations": [
        "Liverpool Hospital, Neurology, Liverpool, NSW, Australia"
      ],
      "name": "Patrick Goorkiz"
    },
    {
      "affiliations": [
        "Liverpool Hospital, Neurology, Liverpool, NSW, Australia"
      ],
      "name": "Daniel Oniell"
    }
  ],
  "title": "3632 Complex ophthalmoplegia and angioinvasive aspergillosis",
  "uid": "8c7ba48d-e4c2-5bd1-8f64-84b2543eb985"
}