Disseminated rhinocerebral mucormycosis: a case report and review of the literature

Rhinocerebral Mucormycosis: An Emerging Threat in the Era of COVID-19

Mucormycosis is a rare but aggressive and fatal infection that is prevalent in immunocompromised patients. The variation in its clinical presentation and the lack of specificity are misleading and lead to a delay in the diagnosis and management. However, the era of coronavirus disease 2019 (COVID-19) is marked by the increasing emergence of Mucor infections, now identified as coronavirus-associated mucormycosis (CAM). Although many clinical forms exist, the most encountered in CAM is rhino-orbito-cerebral, as already reported in India.

We present a case of a 56-year-old male patient with uncontrolled diabetes mellitus and a history of recent SARS-CoV-2 infection treated with IV steroids, presenting for maxillary teeth pain and instability on day 16 of COVID-19 infection. Early diagnosis of CAM is crucial and will help decrease mortality in COVID-19 patients, especially those with comorbidities such as diabetes mellitus. Increasing cases of CAM should prompt clinicians to have a high index of suspicion for rhinocerebral mucormycosis, especially in patients with risk factors receiving steroid therapy.

In such patients, baseline glycosylated hemoglobin level and strict glycemic control by frequently measuring blood glucose levels and strictly adhering to insulin protocols would be rational but its efficacy in limiting the numbers of CAM in developing countries still needs to be confirmed.

COVID-19 y rinosinusitis invasiva aguda secundaria a mucormicosis: a propósito de 2 casos en Colombia

Introducción: la mucormicosis es una infección micótica poco frecuente, también conocida como zigomicosis o phycomycosis, de baja prevalencia, pero con alta mortalidad, por lo regular ocasionada por estados de inmunosupresión como los que ocurren después de infecciones por COVID-19, teniendo esta asociación patológica una alta tasa de mortalidad y secuelas en la salud de los que la padecen. Presentación de los casos: son dos casos de mucormicosis rinocerebral asociados con COVID-19 y se describen el manejo y los desenlaces.

A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years?

BACKGROUND

Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper.

SEARCH STRATEGY

An extensive Medline literature search was performed for case reports published between 1994 and 2015.

RESULTS

In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%.

CONCLUSIONS

Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.

[Rhino-orbito-cerebral mucormycosis from dental origin: Case report]

Rhino-orbito-cerebral mucormycosis from dental origin is an acute infection caused by opportunistic fungi belonging to the order of Mucorales, which affects mainly diabetic and immunocompromised patients.We report the case of a 63-year old diabetic man who performed a dental extraction on himself by his own means and subsequently developed a rhino-orbito-cerebral mucormycosis with cutaneous and palatal affection. The species isolated in the mycological culture was Rhizopus sp.

Survival Without Neurological Impairment of a Patient With Rhino-Orbito-Cerebral Zygomycosis

Rhinocerebral zygomycosis is a rare condition characterized by infection initially in the nose and paranasal sinuses with atypical symptoms consistent with sinusitis. Once established in the nasal sinuses, the infection can easily spread to the orbital region and brain. In the localized form of the infection, the mortality rate is approximately 10%, which increases in the occurrence of orbital involvement and survival in patients of cerebral dissemination is extremely rare. The present paper reports a patient of nasal zygomycosis with orbital and cerebral dissemination in an otherwise healthy patient who survived after 14 months of hospitalization with no neurological impairment. A review of the literature addressing aspects related to diagnosis, treatment, and complications of this fungal infection is also presented.

A case of rhino-orbital mucormycosis in diabetes with haematogenous cerebral spread

We document the first case of haematogenous cerebral spread in Rhizopus arrhizus rhino-orbital mucormycosis, and of posaconazole related adrenal insufficiency. A patient presenting with diabetic ketoacidosis and sinusitis was treated with right medial maxillectomy, ethmoidectomy and IV liposomal amphotericin. Orbital exenteration was performed after intraorbital spread of infection. IV caspofungin and posaconazole was added but complicated by adrenal insufficiency. MRI revealed a new left lentiform nucleus and thalamus rim-enhancing lesion indicating haematogenous cerebral spread.

Neuronavigation-guided endoscopic endonasal resection of extensive skull base mucormycosis complicated with cerebral vasospasm

A 24-year-old woman presented with double vision since 6 months. Examination revealed left eye ptosis and bilateral abducens nerve palsy. Brain computed tomographic scan and magnetic resonance imaging revealed a bone-eroding mass lesion located in the middle skull base, occupying the posterior ethmoidal cells, the planum sphenoidale, the sphenoid sinus, the lateral recesses of the sphenois sinus, the pterygoid apexes, and the middle and lower clivus, with compression of the inferior wall of the cavernous sinus and the parasellar and paraclival parts of the internal carotid artery. The patient was operated on with extended endoscopic endonasal approach guided with neuronavigation. Total mass resection was achieved. Histopathologic examination revealed mucormycosis infectious mass. On postoperative day 5, the patient developed right hemiplegia, and brain imaging revealed left internal carotid vasospasm. After treatment, the patient improved and was discharged.

Basilar artery territory stroke secondary to invasive fungal sphenoid sinusitis: a case report and review of the literature

Background

Mucormycosis is a fungal infection with the following 5 classic forms: cutaneous, pulmonary, gastrointestinal, disseminated, and rhinocerebral. The rhinocerebral form can be rapidly progressive and invasive with a high mortality rate. We present a case of a 38-year-old man with invasive mucormycosis that led to a basilar artery territory stroke. Rhinocerebral mucormycosis is an unusual cause of stroke.

Case Report

A 38-year-old man with a past medical history of diabetes mellitus presented with altered mental status. A lumbar puncture revealed eosinophilic pleocytosis with a mildly elevated total protein and borderline low glucose level. CT revealed a left medullary and cerebellar infarct confirmed by MRI. MRI also displayed a diffuse marrow signal abnormality in the clivus with contiguous sinus disease. Endoscopic sinus surgery confirmed that the fungal sinusitis was mucormycosis of the Rhizopus genus, which had affected the left sphenoid sinus, invaded through the skull base, and involved the basilar artery. He was given liposomal amphotericin (500 mg i.v.) with posaconazole (400 mg i.v. twice daily). Due to the severity of the invasion and poor prognosis, the patient was discharged with comfort care measures.

Discussion

Clinicians should be aware of invasive sinusitis as a rare cause of stroke in diabetics. Once the subarachnoid space and basal arteries of the brain have been invaded, the prognosis is very poor. The key to improvement of outcomes is early recognition and treatment, and examination of the sinuses on neuroimaging in all cases of stroke is vital.

Chronic rhinocerebral mucormycosis: a rare case report and review of the literature

Rhinocerebral mucormycosis is an invasive infection caused by filamentous fungi of the Mucoraceae family. The rhinocerebral form of the disease represents the most common form and has two distinct clinical entities. The common presentation consists of a rapidly progressive infection with high mortality rate, while the other presentation is that of a chronic infection with lower mortality. In the present paper we report a rare case of chronic rhinocerebral mucormycosis. An 85-year-old male with a 6-month history of purulent and odorous nasal discharge, and sporadic episodes of epistaxis and anosmia, presented to the outpatient department of our clinic. Initial cultures were positive only for Pseudomonas aeruginosa. The patient was unresponsive to ciprofloxacin treatment, developing necrotic areas of the nasal septum suspicious for rhinocerebral mucormycosis. Admission to the ENT clinic followed, with histopathologic evaluation of the vomer bone confirming the diagnosis. The patient was treated with amphotericin B and was discharged 3 weeks later on oral posaconazole therapy. Chronic rhinocerebral mucormycosis may present with atypical symptoms or coinfection with another agent. A high degree of clinical suspicion is required for correct diagnosis and prompt initiation of appropriate treatment.

Rhinomaxillary mucormycosis with cerebral extension

Mucormycosis is a rare opportunistic infection caused by fungus belonging to the order Mucorales. A case of a controlled diabetic male with rhino maxillary mucormycosis, with cerebral extension, is described. The patient presented with hemifacial swelling, a nasal twang in his voice, fever, ocular signs, gross tissue destruction, and was sluggish. Early recognition of mucormycosis is necessary to limit the spread of infection, which can lead to high morbidity and mortality. Therefore, health practitioners should be familiar with the signs and symptoms of the disease.

[Rhino-orbito-cerebral mucormycosis, surgical treatment, state of the art]

Rhino-orbito-cerebral mucormycoses constitute a severe fungal infection. These infections mostly arise in immunosuppressed patients. The surgery aiming at resecting necrosed hurts showed its interest in term of survival for lung and cutaneous mucormycosis. However, treatment of rhino-orbito-cerebral location of mucormycosis is not well defined. Transnasal endoscopic surgery allows local control of the disease, better post-operative outcomes than transfacial approaches and less sequelae. However, transfacial approaches are sometimes necessary to allow cutaneous resection or exenteration, the indications of which still remain controversial. The retrospective study of 22 patients with mucormycosis allowed to show that radical surgical treatment allowed local control of the disease with an improved survival. Further prospective studies (PHRC MICCA, current) are required to standardize the management of this rare but potentially lethal pathology.

Mucormycosis of mandible with unfavorable outcome

Mucormycosis is a fulminant fungal infection that occurs most often in diabetic and immunocompromised individuals. Our patient, with uncontrolled diabetes mellitus and multiple systemic disorders, developed postextraction mucormycosis of mandible, an extremely rare complication. An initial clinical and radiographic diagnosis of mandibular osteomyelitis was made and the lesion was treated medically and surgically with curettage and saucerisation. The specimen was sent for histopathological evaluation, which showed necrotic area containing broad aseptate fungal hyphae with right angle branching consistent with mucormycosis. The patient succumbed to multipleorgan failure secondary to septicemia. The disease is usually fatal with a poor survival rate; there is still paucity of literature on the definitive management of this disease involving the mandible. This paper emphasizes the need for correction of underlying immunodeficiency and early diagnosis with aggressive multimodality treatment approach to offer the best chance of survival.

Mucormycosis of the head and neck: report of five cases with different presentations

Mucormycosis is a lethal fungal disease with a general poor prognosis. Rhinocerebral presentation is the more frequent form. The purpose of this study was to review and show our experience in the management of 5 cases of mucormycosis of the head and neck with different clinical presentations. The high suspicion led us a prompt diagnosis and aggressive surgical treatment that allowed a good outcome in our series.

Rhinomaxillary mucormycosis: A palatal ulcer

Rhinocerebral mucormycosis (zygomycosis) is an opportunistic fungal infection caused by saprophytic fungus. It involves several areas of the body, but the rhinocerebral form is most relevant to health care providers. Zygomycosis is associated with medically compromised patients. Our case reports an unhealed ulcer present over the palate of 15 days duration associated with swelling over the maxillary sinus region. This case is a blend of clinical, radiological, and histological manifestations of mucormycosis in a patient.

Management and outcomes of three cases of rhinocerebral mucormycosis

Mucormycosis is a rare opportunistic infection caused by fungi belonging to Mucorales order. The infection usually starts in the middle or inferior nasal meatus and then spreads to the paranasal sinuses and the orbit. Then it reaches the brain through the ethmoid and the orbit apex and can lead to lethargy, paralysis, and death. The majority of cases of rhinocerebral mucormycosis are diagnosed in patients with immunologic and metabolic disorders. Early diagnosis is fundamental, and so is medical therapy with amphotericin B along with surgical toilet of the compromised tissues. This article presents and discusses the management of 3 cases of rhinocerebral mucormycosis with different onsets, progressions, and outcomes.

Unilateral proptosis in a 60-year-old man

A 60-year-old immunocompromised patient developed rapidly progressive proptosis that was secondary to mucormycosis. This life-threatening fungal infection usually is associated with chemosis, proptosis, ophthalmoplegia, and visual loss. The fungus may invade ocular structures, sinuses, and extend into the brain. The standard of care includes correction of the underlying condition, administration of liposomal amphotericin B with posaconazole, and surgical debridement of infected and necrotic tissue. We present a case of unilateral proptosis due to mucormycosis in an immunocompromised patient. The patient was successfully managed medically without exenteration. The indications for exenteration are currently unclear, and no clinical guidelines exist.

Orbitomaxillary mucormycosis (zygomycosis) and the surgical approach to treatment: perspectives from a maxillofacial surgeon

Rhinocerebral or rhino-orbitocerebral (mucormycosis) zygomycosis (ROCZ) usually occurs among patients with poorly controlled diabetes mellitus (especially those with ketoacidosis), solid malignancies, iron overload or extensive burns, in patients undergoing treatment with glucocorticosteroid agents, or in patients with neutropenia related to haematologic malignancies. The disease process starts with inhalation of the fungus into the paranasal sinuses. The fungus may spread to invade the palate, sphenoid sinus, cavernous sinus, orbits or cranially to invade the brain. Pain and swelling precede oral ulceration and the resulting tissue necrosis can result in palatal perforation. Infection can sometimes extend from the sinuses into the mouth and produce painful, necrotic ulcerations of the hard palate. If untreated, infection usually spreads from the ethmoid sinus to the orbit, resulting in the loss of extraocular muscle function and proptosis. Surgical treatment includes the resection of involved tissues of the face, including skin and muscle, any skin of the nose that is involved, maxillary and ethmoid sinuses, necrotic tissue of the temporal area and infratemporal fossa, and orbital exenteration. The keys to successful therapy include suspicion of the diagnosis and early recognition of the signs and symptoms, correction of underlying medical disorders such as ketoacidosis, and aggressive medical and surgical intervention.

Rhino-orbito-cerebral mucormycosis: report of two cases and review of the literature

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare, fulminant opportunistic fungal infection that is mostly seen in immunocompromised or diabetic patients. The disease should be recognised and treated immediately. We present here MR imaging findings of two patients with histopathologically proven ROCM. One of the cases had a history of corticosteroid treatment and iatrogenic diabetes mellitus and although amphotericin B was started immediately, the disease progressed and surgical debridement was necessary. The second case was a patient with diabetes mellitus type 1 in whom ROCM had occurred following an abdominal surgery; amphotericin B treatment alone was adequate in this patient.

Mucormycosis Mimicks Sinusitis in a Diabetic Adult

Fungal sinusitis caused by invasive fungal infections, such as Mucormycosis, occurs predominantly in an immunocompromised patient. However, invasive cranial bone mycoses are rare and are usually associated with host immunodeficiency. They are difficult to diagnose, and in many cases are fatal. Treatment consists of antifungal chemotherapy, radical surgical debridement, and control of the underlying immunological condition. We report a case of Mucormycosis in a patient with type 1 diabetes mellitus. The patient had a history of dental pathology and associated renal dysfunction. The patient was managed by extensive surgical debridement followed by amphotericin B lipid complex injection (Abelcet 5 mg/bw kg/day) as an antifungal agent. Our patient's ocular function was affected. The radical treatment and follow-up by a multidisciplinary team eliminated the mucor-related consequences, however, the patient died because of end-stage renal failure. In conclusion, type 1 diabetes may be associated with invasive fungal sinusitis.