Case 1
40 Y/O man came to the emergency room with a seizure, reduced level of consciousness (LOC), and headache. In the last five days, she experienced fever and malaise. On examination, there was mild ptosis with restricted movement toward the right in the right eye suggesting right abducens nerve damage accompanied by impaired visual acuity and color vision. There wasn’t any sign of palate necrosis or nasal discharge. Kernig sign was negative however specimen from lumbar puncture evidenced meningitis.
Patients declared a history of diabetes with regular insulin usage and Coivd-19 infection in the past two months. A Chest CT scan denoting an ongoing COVID-19 infection was obtained (figure 1). The patient had experienced uncontrolled blood sugar (Blood Sugar = 548 mg/dL) during the usage of broad-spectrum antibiotics along with corticosteroids at the time of the COVID-19 infection. We also recorded a rise in creatinine (highest blood creatinine  =3.3 mg/dL) during treatment.
Imaging evaluation revealed CNS findings as depicted in figure 1. Suggesting mucormycosis or other bacterial infection mimicking low-grade glioma therefore we started broad-spectrum antibiotics accompanied by liposomal amphotericin B (5 mg/kg) followed by definitive surgery.
There were no sinonasal symptoms but due to the origin of the lesion that was seen from below, we chose the Endoscopic transnasal corridor. After ethmoidectomy, we encountered frank puss and granulation tissue as white creamy material. The grand and basal lamellae were destroyed. We entered the cranial cavity; a Frontal basal abscess was drained and copious irrigation was implemented. We took advantage of the absence of arachnoid bridge and CSF leakage and let the skull base be opened to the nasal cavity for further abscess drainage.
Despite our expectations for suppurative bacterial infection pathological findings were:
Section of brain tissue shows well-formed and occasionally coalescing granulomas composed of epithelioid histiocytic multinucleated giant cells, lymphocytes, and central neutrophilic microabscesses with an area of necrosis containing fragmented broad fungal hyphae with right-angle branching and no septation, perivascular inflammation, astrogliosis, and edema are noted which is diagnosed as necrotizing granulomatous encephalitis consistent with mucormycosis without any evidence of malignancy.
In the course of treatment, the patient’s headache and drowsiness worsened. New imaging revealed aggravation of cerebral edema and persistent frontal mass effect. Hence, unilateral frontal craniotomy and removal of necrotic tissues were performed, and it was attempted to close the base defect with fascia lata and decompress the frontal lobe.
After the surgery, three sessions of retrobulbar amphotericin B (5mg/kg) were injected by ophthalmologists due to orbital apex syndrome (OAS). Nasal endoscopy was normal before discharge. finally, the patient was discharged after two months without any visual deficit or headache. He was prescribed to use posaconazole (300 milligrams) and antibiotics. After 3 months of follow up patient has not experienced any significant neurological sing and symptoms including headache, altered LOC, and visual defects along with any recurrence manifestation.
Fig. 1. The parenchymal lesion in left frontal base with mild enhancement paranasal sinus involvement in T1 with D, E: Chest CT scan illustrating COVID-19 involvement F: hypodensity in left frontal base.