We discuss a case of a 64 yo man with hypertension, hyperlipidemia and diabetes mellitus from Bangladesh who presented with one month of right eye vision loss, headache, jaw pain, temple tenderness, and loss of appetite. He initially reported sudden onset of blurry vision accompanied by right-sided headache, which progressed in one month to complete blindness. CT maxillofacial imaging showed enhancement of the right orbital apex/optic canal with erosion of the adjacent lateral wall of the sphenoid sinus. Physical exam was notable for complete right eye ptosis, right eye pain and lack of reaction to light, as well as third and sixth right cranial nerve palsies. Lab results were notable for HA1c of 9.5. Sphenoidal biopsy revealed a fungal ball and Grocott methenamine silver (GMS) stain confirmed acute-angle branching, septated hyphae consistent with Aspergillus fumigatus.

He was started on amphotericin B treatment, which was later switched to isavuconazole. Neurosurgery was consulted for possible debridement but family declined surgery. He ultimately survived hospitalization and was discharged but a follow-up MRI scan 3 months later showed new subacute right middle cerebral artery (MCA) watershed territory infarction.