Presentation
History of recent COVID-19 infection of moderate severity, treated with steroids. Presents with left facial and orbital pain.
Patient Data
Mucosal thickening with fluid levels are seen involving bilateral maxillary, ethmoid, left frontal and bilateral sphenoid sinuses with obliteration of osteo-meatal complexes.
T2 isointense contents are seen in left ethmoid, left maxillary & left sphenoid sinuses with heterogeneous enhancement. There is heterogeneously enhancing soft tissue in left inferior periorbital, left premaxillary & retroantral regions.
There is thickening and edema of left pterygoid, left masseter & inferior portion of left temporalis muscles. Peripherally enhancing collection seen in left masseter muscle & left retroantral region, measuring 2.5 x 3.5 x 3.9 cms (AP x TR x CC).
There is extension of soft tissue into inferior extraconal space of left orbit with thickening and edema of inferior rectus muscle. Left intraorbital contents appear normal.
There is also enhancing soft tissue in bilateral nasal cavities with mid and posterior nasal septal perforation.
There is also T2hypointense thickening along the surface of bilateral turbinates. There is contiguous areas of non-enhancement involving posterior portions of left middle and inferior turbinates and adjacent nasal septum - indicating devitalised mucosal tissue, due to ischemia.
There is also poor or absent enhancement of portion of hard palate - indicating ischemia.
Mild heterogeneous enhancement is noted in middle cranial fossa skull base - indicating contiguous inflammation.
These overall features are suggestive of aggressive fungal sinusitis with left orbital and skull base involvement.
Case Discussion
Mucormycosis (black fungus) is a fulminant, locally agressive fungal infection of paranasal sinuses with variable extension into orbits, infratemporal fossa and brain. It usually affects immunocompromised patients and patients with uncontrolled diabetics.
In the current widespread second wave of COVID-19 pandemic in India, the COVID-19 recovered or treated patients are presenting with mucormycosis.
Knowledge of early signs and symptoms of the disease can prompt early diagnosis by MRI with gadolinium contrast, where the fungal elements appear as T2w hypointense foci with variable degree of non-enhancing devitalised mucosa in affected parts.