Rhino-orbito-cerebral mucormycosis

Case contributed by Brenda Gabriela Medina

Presentation

Starts a week ago with eyelid edema, retroocular pain and purulent rhinorrea. He has type 2 diabetes mellitus of recent diagnosis with poorly control. Currently with neurological deficit and frontal pain.

Patient Data

Age: 35 years old
Gender: Male

Brain MRI with gadolinium

mri

MRI images demonstrate multiple soft tissues lesions invading the right orbit, right maxillary sinus and left frontal sinus that appears low signal in T1, high signal in T2, shows restriction at DWI/ADC and heterogeneously enhancement at the gadolinium application, with no evidence of fat-suppression. There's severe compromise at the right orbit with proptosis and vivid enhancement at the optic nerve. Both masticator spaces shows intense enhancement at post gadolinium sequences.  

At brain in both frontal lobes and right basal ganglia region there's two irregular and low signal lesions at T1, high signal at T2, with classic ring enhancement after gadolinium application, DWI/ADC restriction and associated with extensive edema, these findings consists with brain abscesses.

Additional findings: surgical changes by turbinectomy at right nasal cavity. 

Case Discussion

This is a classic case of mucormycosis with Zygomycetos as the causal organism, after nasal biopsy confirmed it. The patient had bad control in his recent diagnosed diabetes, leading to a high morbidity and mortality.

The manifestations in this case are typical for the disease, spreading to the paranasal sinuses and subsequently to the orbit, meninges and brain by direct extension. Abscesses  were present at advanced stages.  

The MRI shows lesions tending to be isointense or hypointense in all sequences. After the administration  of gadolinium the lesions had variable enhancement patterns, with the classic ring enhancement in the brain abscess as the most representative. An aggressive sinonasal and orbital inflammatory process is observed too.

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