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.