Presentation
A known non-controlled diabetic patient presented with progressive headache , and confusion as well as was eventually admitted to the hospital with disturbed consciousness.
Patient Data
Mucosal thickening and partial opacification of both maxillary antra, ethmoid air cells (more marked on the left), and the left compartment of the frontal sinus. They show moderate heterogenous post-contrast enhancement mucosal enhancement more marked at left ethmoidal and frontal sinuses with multiple small non-enhanced hyphae eliciting low signal intensities (black turbinate sign).
Rarefaction and tiny focal interruption of the left lamina papyrecia are noted associated with triangular shaped area of abnormal signal intensity intra-orbital extension with deep extending laterally between medial and superior recti muscle extending intra-conal with retro-bulbar engulfment encroaching on the left optic nerve and optic canal reaching the orbital roof, measuring about 3.1X1.6x1.1 cm in maximum dimensions. The such lesion appears of low T1 and high T2 signal. The post-contrast study shows moderate enhancement with a small non-enhanced component inside.
Additionally left frontal small cortical and subcortical marginally enhanced foci (few millimeters) associated with surrounding left frontal perifocal edema of bright T2, FLAIR signal, moreover, dural enhancement of left frontal meninges is also seen
Blurring of the left retro-bulbar fat shows exaggeration of its bright signal intensity in T2WIs.
The left medial, superior recti and superior oblique muscles appear swollen, edematous, and slightly displaced. Otherwise, normal appearance of the rest of the extra-ocular muscles.
Subsequent minimal forward proptosis of the left eye globe is noted.
Mild swelling of the left cavernous sinus however it is still patent
Nasal septal defect is also noted.
Normal appearance of the right optic nerve, and retro-orbital fat.
Small foci of bright T2 and FLIAR signal while of low T1 signal are seen in both deep temporal and deep parietal regions, brain stem (multiple lacunar infarctions), Multiple bilateral periventricular white matter patchy areas of abnormal bright T2 and FLAIR signal intensities while indistinct in T1WIs are seen in both frontal and parietal regions denoting white matter hypoperfusion (small artery disease).
Prominent ventricular system and extra-axial CSF spaces denoting central and peripheral involutional changes.
Case Discussion
The imaging findings, taken together with the clinical data, are impressive for acute invasive fungal sinusitis with orbital, meningeal, and cerebral involvement. The pattern of partial non-enhancement of the sinonasal mucosal lining and medial left orbital soft tissues thickening/phlegmon indicated necrosis due to angioinvasion,
The patient underwent sino-nasal endoscopy, which shows fungal colonization.
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