Rhino-orbito-cerebral mucormycosis (ROCM) with internal carotid artery stenosis in a diabetic patient with caries tooth and oroantral fistula

Intraluminal arterial transit artifact as a predictor of intracranial large artery stenosis on 3D time of flight MR angiography: Expanding the application of arterial spin labeling MRI in ischemic stroke

Objectives

The objective of this study was to evaluate the diagnostic value of "intraluminal arterial transit artifact" in the prediction of intracranial large artery stenosis and to determine if this finding is predictive of ischemic stroke in the territory of the involved artery.

Material and Methods

The presence of arterial transit artifact (ATA) within the lumen of an intracranial large vessel was noted on three-dimensional time of flight (3D-TOF) magnetic resonance angiography (MRA) (ATA group). The patients with stenosis but with no ATA (no-ATA group), patients with total occlusion (total occlusion group), and patients with no stenosis/occlusion (normal group) were included in the analysis.

Results

There were four groups of patients included in the final analysis, the ATA group (n = 22), the no-ATA group (n = 23), the normal group (n = 25), and the total occlusion group (n = 9). Among patients with any demonstrable stenosis (n = 45), the presence of ATA within the stenotic segment was predictive of stenosis of ≥56% (Sensitivity of 100% [85.2-100, 95% CI], specificity of 100% [86.4-100, 95% CI]), with area under curve of 1.0 (0.92-.0, 95% CI). The presence of intra-arterial ATA signal was significantly associated with ischemic stroke as compared with the no-ATA group (86.36% vs. 26.08%, P = 0.0003). Intraluminal ATA was found to be an independent predictor of infarction in the territory of the involved artery.

Conclusion

Intraluminal ATA is predictive of stenosis of at least 56% in the involved artery on 3D-TOF MRA. Intraluminal ATA sign may be an independent predictor of infarction in the territory of the involved artery.

Isolated Fungal Sphenoid Sinusitis With Cavernous Sinus Thrombophlebitis: A Case Report

Cavernous sinus thrombophlebitis is a rare, potentially life-threatening, condition that is most often caused by gram-negative bacteria and, to a lesser extent, fungi. Mucor is an opportunistic fungus that frequently affects patients with a weak immune system. We describe a case of an adult female without diabetes who developed Mucor sphenoid sinusitis causing cavernous sinus thrombophlebitis. The patient presented with headache, diplopia, and right lateral rectus palsy. Cranial magnetic resonance imaging (MRI) showed abnormal prominent enhancement involving the cavernous sinuses associated with interspersed internal non-enhancing components indicating bilateral cavernous sinus thrombophlebitis and exuberant inspissated secretions within the left sphenoid sinus. After administering enoxaparin and intravenous antibiotics, the patient underwent endoscopic transnasal sphenoidotomy with nasal polypectomy. Culture results showed growth of mucor, for which the patient received itraconazole. Thereafter, complete resolution of headache, diplopia, and right lateral rectus palsy was observed. On follow-up, no residual neurologic deficits were noted. The repeat cranial MRI showed no abnormality involving the cavernous sinuses, with no evidence of cavernous sinus thrombophlebitis and normal paranasal sinuses. While a few case reports have been available on cavernous sinus thrombophlebitis caused by fungal sphenoid sinusitis with Mucor as the primary organism, none have involved immunocompetent individuals.

Epidemiology, clinical features, diagnosis and treatment of cerebral mucormycosis in diabetic patients: A systematic review of case reports and case series

BACKGROUND

Patients with diabetes are known as an important high-risk group for cerebral mucormycosis (CM).

METHOD

We conducted a structured search using PubMed/MEDLINE to collect both case reports and case series case (ie including at least two patients) onto CM in diabetic patient published between 2000 and March 2020.

RESULTS

Forty-five reports of individual cases and eighteen case series articles were included. India accounted for the largest share of reports with 37.7% and 38.8% of individual cases and case series, respectively. Mortality ranged from 0% to 100% in the case series. The overall mortality in the individual cases was 46.3%, and 64.2% of deaths were reported in patients with ketoacidosis diabetes. Facial swelling (53.3%), headache (44.4%), loss of vision (35.5%) and ophthalmoplegia (35.5%) were the most frequently reported clinical symptoms. In all patients except 4 (91.1%), CM was treated surgically; however, in many cases (42%), despite the use of surgery, death occurred. Amphotericin B deoxycholate (AMB) and lipid-based AMB (LAMB) were used as the first lines of treatment for all patients; however, posaconazole, echinocandins, hyperbaric oxygen therapy (HBOT) and deferasirox were used in combination for a number of patients. Posaconazole has been shown to have positive therapeutic effect; however, posaconazole, LAMB and HBOT are not commonly used in low-income and health-challenged countries.

CONCLUSION

Cerebral mucormycosis is a rapidly progressive infection in diabetic patients and carries immense morbidity despite early diagnosis and treatment. Low-income countries have had the highest number of reports of the disease in recent years, indicating the need to control diabetes in these countries.