Rhino-orbito-cerebral mucormycosis

Case contributed by Dr Francis Deng

Presentation

History of acute myeloid leukemia treated with bone marrow transplant. New left proptosis and fixed dilated pupil.

Patient Data

Age: 35 years
Gender: Male

Brain MRI

MRI
  • left anterior frontal lobe restricted diffusion
  • bilateral anterior frontal lobe brain parenchymal enhancement
  • dural enhancement along the central anterior skull base

Face MRI

MRI
  • fluid in left sinonasal tract and stranding in left orbital fat
  • nonenhancing left sinonasal mucosa
  • nonenhancement of left palatal mucosa and left medial orbital tissues
  • left proptosis with tenting of the globe at the optic nerve insertion and stretching/straightening of the optic nerve
  • edema at the left temporal fossa superficial soft tissues

No intracranial large vessel occlusion.

Case Discussion

The imaging findings, taken together with the clinical history, most likely represented acute invasive fungal sinusitis with orbital, meningeal, and cerebral involvement. The nonenhancement of the left sinonasal mucosal and medial left orbital soft tissues indicated necrosis due to angioinvasion, as did the infarct of the left anterior frontal lobe.

The patient underwent nasal endoscopy, which revealed grey, necrotic mucosa.

Histopathology:

SINUS BIOPSY, LEFT:
Invasive fungal sinusitis with both vascular and stromal invasion; see note. 

Note: The fungi are composed of branching hyphae with a morphologic differential diagnosis of Aspergillus and Mucormycosis; microbiogical correlation, with cultures currently pending, is needed for speciation.

Microbiology:

FUNGAL CULTURE:

RHIZOPUS SPECIES

Follow-up:

This case demonstrates rhino-orbito-cerebral mucormycosis, due to Rhizopus spp. The patient was started on intravenous amphotericin. Owing to the grave prognosis of this infection with antifungal medical therapy alone, as well as the expected morbidity of extensive surgical debridement, the goals of care were changed to comfort measures only. The patient expired within several days.

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