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