眼窩尖端部症候群にて発症した浸潤型副鼻腔～眼窩アスペルギルス症の1例

A Case of Invasive Sino-orbital Aspergillosis Developing Orbital Apex Syndrome

Ⅰ．はじめに

　眼窩尖端部症候群（orbital apex syndrome）は，上眼窩裂を走行する各脳神経症状，および視力障害を主徴とし，主な原因として眼窩尖端部の炎症，腫瘍，外傷が挙げられる．稀ではあるが，中枢神経アスペルギルス感染によるものも報告されている．中枢神経アスペルギルス症は，HIV感染，ステロイド長期使用者など易感染性宿主の増大に伴い患者数は増加しつつあり，治療抵抗性で予後不良の疾患である．

　眼窩尖端部症候群を初発症状とし，抗真菌剤に対し抵抗性であった浸潤型副鼻腔～眼窩アスペルギルス症に対し，原疾患治療および疼痛緩和を目的として積極的外科切除を行い，術後の抗真菌薬投与にて良好な経過を辿った1例を経験したので，文献的考察を加え報告する．

　Sino-orbital invasive aspergillosis has been regarded as a lethal disease. The authors report a case with a successful treatment result. A 65 year-old woman, with mild diabetes mellitus, presented progressive right visual disturbance, diplopia, ptosis, and severe periorbital pain over a period of 2 weeks. MR images with gadolinium contrast showed a heterogeneously enhanced mass extending from the right orbital apex to the cavernous sinus. Despite steroid pulse therapy, her symptoms progressed. An open biopsy revealed invasive sino-orbital aspergillosis. Intravenous and oral antifungal agents were administered, but the aspergilloma gradually expanded. Her general status deteriorated due to intractable periorbital pain that was resistant to narcotic analgesics. By a craniotomy, the aspergilloma involving the orbit and cavernous sinus was radically removed leaving the internal carotid artery intact and simultaneously rhizotomy of the trigeminal nerve was carried out. The postoperative course was uneventful and the pain was remarkably ameliorated. Three years after the surgery, she has been well, receiving voriconazole and experiencing no relapse of the disease.