Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review

Cerebritis, optic ischemia, and cavernous sinus thrombosis arising from sinonasal mucormycosis

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

Combination endoscopic surgical debridement and transcutaneous retrobulbar amphotericin B for acute rhino-orbital-cerebral aspergillosis

PURPOSE

To report a case of acute rhino-orbital-cerebral aspergillosis with aggressive intracranial and orbital extension co-managed medically and surgically with endoscopic sinus debridement and multiple retrobulbar injections of amphotericin B.

OBSERVATIONS

A 70-year-old male patient presented via external transfer with headaches and left ophthalmoplegia concerning for severe complicated sinusitis with intracranial and left orbital spread. His history is notable for a simultaneous heart-kidney transplant three years prior on chronic immunosuppression. Ophthalmologic examination revealed complete ophthalmoplegia in the left eye with no light perception concerning for a left orbital apex syndrome. The patient was taken to the operating room twice for endoscopic sinus debridement and three separate retrobulbar injections of amphotericin B. Fungal cultures from surgical specimens grew isolated Aspergillus fumigatus. Patient's symptoms gradually improved and repeat MRI demonstrated resolution of pansinusitis, sparing left eye exenteration.

CONCLUSIONS AND IMPORTANCE

Multidisciplinary management of invasive fungal rhinosinusitis in the setting of profound immunosuppression poses a significant challenge. While surgical debridement remains the cornerstone approach, the achievable reduction in disease burden may be augmented by targeted retrobulbar antimicrobials.

MR imaging spectrum in COVID associated Rhino-Orbito-Cerebral mucormycosis with special emphasis on intracranial disease and impact on patient prognosis

In the wake of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, a new epidemic of COVID associated mucormycosis (CAM) emerged in India. Early diagnosis and prompt treatment of this deadly disease are of paramount importance in improving patient survival. MRI is the cornerstone of diagnosis of early extrasinus disease, particularly intracranial complications which have traditionally been associated with a high mortality rate. In this review, we depict the sinonasal, perisinus, orbital and intracranial involvement in CAM. Special emphasis is laid on intracranial disease which is categorized into vascular, parenchymal, meningeal, bony involvement and perineural spread. Vascular complications are the most common form of intracranial involvement. Some unusual yet interesting imaging findings such as nerve abscesses involving the optic, trigeminal and mandibular nerves and long segment vasculitis of the internal carotid artery extending till its cervical segment are also illustrated. In our experience, patient outcome in CAM (survival rate of 88.5%) was better compared to the pre-pandemic era. Presence of intracranial disease also did not affect prognosis as poorly as traditionally expected (survival rate of 82.8%). Involvement of brain parenchyma was the only subset of intracranial involvement that was associated with higher mortality (p value 0.016). The aim of this review is to familiarise the reader with the MR imaging spectrum of CAM with special focus on intracranial complications and a brief account of their impact on patient prognosis in our experience.

The Integral Role of Radiology in the Diagnosis and Management of COVID-19-Associated Mucormycosis Infections

Recently, there has been a sudden surge in COVID-19-associated mucormycosis (CAM) infections. Rhino-oculo-cerebral and pulmonary mucormycosis are the two most common forms of CAM. Radiology plays an integral role in the management of CAM. Computed tomography (CT) determines gross bony and soft tissue involvement in COVID-19-associated rhino-oculo-cerebral mucormycosis, whereas magnetic resonance imaging helps in evaluation of the orbital and intracranial extension. Paranasal sinus soft tissue with extrasinus infiltration with or without bony destruction is suggestive of COVID-19-associated rhino-oculo-cerebral mucormycosis. High-resolution CT chest scan has shown to be helpful in the diagnosis of COVID-19-associated pulmonary mucormycosis. Consolidation and cavitation are the most common imaging features. Other CT abnormalities include the reverse-halo sign, pleural effusion, ground-glass opacities, pneumothorax, nodules, and pulmonary embolism. A high index of suspicion with appropriate imaging findings can lead to the early diagnosis of CAM and timely initiation of antifungal treatment and/or surgical debridement, which can be lifesaving.

Decoding "guitar pick sign" in COVID-19-associated mucormycosis: A case series

“Guitar pick sign,” also referred to as posterior globe tenting, is a radiological surrogate marker of tense orbit and profound vision loss. It is seen commonly in traumatic retrobulbar hemorrhage and carotico-cavernous fistula and less frequently in orbital cellulitis, subperiosteal abscess, and invasive fungal infections. We report a case series of Coronavirus disease-19–associated rhino-orbito-cerebral mucormycosis with guitar pick sign, of which none survived, and discuss the causative pathomechanisms, severity grade, and the clinical relevance of this unique radiological finding.

Fonsecaea associated cerebral phaeohyphomycosis in a post-COVID-19 patient: A first case report

Phaeohyphomycosis, previously known as chromoblastomycosis, is a chronic mycosis, usually affecting the skin. It is caused by dematiaceous fungi, which are a group of fungi that produce melanin in their cell walls. Cerebral phaeohyphomycosis occurs as a part of invasive presentation of the fungi, which usually affects immunocompromised patients, but may affect immunocompetent individuals as well. Cerebral infection in phaeohyphomycosis is associated with a poor prognosis regardless of the immune status of the patient. COVID-19 SARS-CoV-2 infection and/or medications used for its treatment may compromise the immune system, including in the post-COVID-19 period, resulting in invasive fungal infections, which have frequently been reported recently during the COVID-19 pandemic. We report a case of Fonsecaea associated cerebral phaeohyphomycosis in a recently diagnosed diabetic Omani lady, who presented to our hospital 6 weeks after recovery and discharge from hospitalization for moderate COVID-19 pneumonia.