Case 2
Our second case is a 50Y/O man who presented with seizures (2 times), headache, obtundation, left mild proptosis, and orbital pain since 2 weeks ago; 3 weeks after recovery from COVID-19 infection. At the physical examination, we didn’t find further remarkable neurological signs.
The patient had a history of diabetes mellitus. COVID-19 was confirmed by PCR and corticosteroid usage was noted in this treatment regimen. Based on the probability of mucormycosis, we started liposomal IV amphotericin B (5 mg/kg) and broad-spectrum antibiotics followed by the surgery.
Although MRI defined intracranial mass and edema, because of the involvement of ethmoid sinus and continuation of epidural collection to sinonasal space we had a preliminary diagnosis of purulent complicated sinusitis with epidural empyema and chose the intranasal endoscopic path to open affected sinuses and brain epidural puss and irrigation. We found black debris and puss characteristics of sinonasal mucormycosis. Ethmoidectomy and entrance to epidural space ensued.
Despite the specimen and puss was not confronting a classic fungal mucormycosis infection, the pathology was: Left periorbital soft tissue debridement is necrotic and inflamed fibro adipose tissue with non-septate right-angle branching hyphae which is morphologically consistent with mucormycosis fragments of inflamed and necrotic respiratory mucosa present Middle turbinate and bilateral ethmoidal sinus debridement, focally necrotic respiratory mucosa with non-necrotizing granulomatous inflammation no fungal element identified in this sample.
A week after surgery, sinus endoscopy revealed septum necrosis so we resected the crust, and the sinuses were washed. patient’s diabetes was controlled by our endocrinologist during the treatment course and finally after the one-month patient was discharged from the hospital without visual defect or headache. During the last three months of follow-up, there is no evidence of significant neurological problems as well as any recurrence of the infection.
Fig. 2 A, B, C: hypointense lesion in T1 with ring enhancement in left anterior skull base and frontal base which spreads to the medial part of left orbit D: ethmoidal erosion in bone window CT scan