Rhinocerebral mucormycosis: MR manifestations

Rhino-Orbital Cerebral Mucormycosis in a Healthy Female Child: Case Report

Mucormycosis is a potentially fatal condition with a high mortality rate, particularly when there is extra nasal involvement, and it is rare for patients with fungal brain disease to survive. It mostly affects patients who are metabolically or immunologically compromised, which constitutes one of the three classical stages of the progression of Rhino-Orbito-Cerebral Mucormycosis (ROCM). Stage I: infection of the nasal mucosa and paranasal sinuses; Stage II: orbital involvement; Stage III: cerebral involvement.Here, we report a case of rhino-orbital cerebral mucormycosis in a 14-year-old girl with no known risk factor who presented with periorbital edema, right eye proptosis, fever, and extreme facial pain, which progressively worsened to confusion and left leg weakness in 3 days after admission. The final diagnosis was rhino-orbital-cerebral mucormycosis. The infection was successfully treated using liposomal amphotericin and surgical debridement to remove infected orbital tissue. Mucormycosis is a potentially fatal disease that necessitates prompt diagnosis and treatment. Children are rarely infected with mucormycosis. The majority of studies show that people are typically between 40 and 50 years old. ROCM is typically diagnosed using clinical symptoms and histopathologic evaluation; however, imaging is critical in determining the presence of intracranial lesions. The standard treatment for ROCM is amphotericin B at a recommended dose of 1.0-1.5 mg/kg/day for weeks or months, depending on the clinical response and severity of adverse drug reactions, particularly nephrotoxicity.Rhino-orbital cerebral mucormycosis in a healthy female child is uncommon; early diagnosis and prompt treatment with Amphotericin B should be necessary. Devastating consequences will result from a delayed diagnosis.

Sinonasal and Orbital Imaging Findings in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of COVID-19: A Retrospective Cohort Study in a Tertiary Hospital in Central India

Background Mucormycosis is a consequence of the angioinvasive disease caused by filamentous fungi that belong to the order Mucorales, particularly Mucor, Rhizopus, and Rhizomucor. Rhizopus oryzae is the most prevalent form. The invading hyphae lead to damage of blood vessels leading to thrombosis and consequent tissue necrosis. The incidence of this disease entity witnessed a significant rise during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. Timely diagnosis and prompt treatment are crucial to diminish both the mortality and morbidity associated with this disease. Imaging plays a pivotal role in diagnosing the ailment, evaluating its extent, identifying complications such as thrombosis, and facilitating surgical planning. It demonstrates exceptional sensitivity in detecting the disease at its early stages, often before symptoms manifest. Due to the angioinvasive nature of Mucor, early detection assumes utmost importance as it necessitates intensive antifungal therapy and the removal of devitalized tissue through debridement. Methodology We conducted a retrospective cohort study to analyze computed tomography (CT) imaging findings in patients with COVID-associated rhino-orbito-cerebral mucormycosis (ROCM) confirmed by histopathological examination. We compared these findings with CT findings of the nose and paranasal sinuses in patients without mucor following COVID-19 sinusitis (non-ROCM). Results All 16 cases in the non-ROCM group were in stage 1 disease. In contrast, in the ROCM group, three patients had stage 1 disease, five patients had stage 2 disease, and 10 patients had stage 3 disease (p = 0.0001). The pterygopalatine fossa was significantly affected in 10 of 18 ROCM patients and in none of the non-ROCM patients. Conclusions Imaging plays a crucial role in the early detection of mucormycosis. It assists treating physicians in initiating prompt and aggressive treatment, thereby improving the prognosis of this frequently fatal disease.

Rhino-orbito-cerebral Mucormycosis: Pictorial Review

Mucormycosis (MCR) is a fulminant, potentially lethal, opportunistic fungal infection. Diabetes, immunocompromised states and elevated serum iron levels are the most important risk factors for contracting MCR infection. Recently, MCR co-infections have been observed in patients with COVID-19 disease owing to a complex interplay of metabolic factors and corticosteroid therapy. Rhino-orbito-cerebral mucormycosis (ROCM) is the most common clinical form of MCR infection and refers to infection of the nasal cavities, paranasal sinuses, neck spaces, orbits and intracranial structures. Sinonasal inoculation is typically the primary site of infection; the necrotising and angioinvasive properties of the fungus facilitate its spread into adjacent structures. In this review, we discuss the pertinent mycology and risk factors of MCR infection. The review also aims to acquaint the reader with the cross-sectional imaging appearances of ROCM and its complications. All the cases discussed in this pictorial essay are microbiologically and/or histopathologically proven cases of ROCM with concomitant COVID-19 infection.

Infectious ophthalmoplegias

Though infections account for a significant proportion of patients with ocular motor palsies, there is surprising paucity of literature on infectious ophthalmoplegias. Almost all types of infectious agents (bacteria, viruses, fungi and parasites) can lead to ocular motor palsies. The causative infectious agent can be diagnosed in most cases using an orderly stepwise approach. In this review we discuss how to approach a patient with ophthalmoplegia with main focus on infectious etiologies.

Central retinal artery occlusion as the presenting manifestation of invasive rhino-orbital-cerebral mucormycosis

Rhino-orbital-cerebral mucormycosis (ROCM) is a rare but devastating fungal infection caused by filamentous fungi of the family Mucoraceae. We report a rare case of unilateral ROCM in a diabetic patient where central retinal artery occlusion (CRAO) was the first manifestation of the disease. Magnetic resonance imaging scan revealed orbital and intracranial spread of the disease. Definitive diagnosis was established by culture of the biopsy specimen which showed Rhizopus oryzae on Sabouraud's dextrose agar. The patient was successfully treated with extensive debridement of sinuses and intravenous liposomal amphotericin B; however, the left eye remained blind following the CRAO.

Usefulness of Computed Tomography and Magnetic Resonance in Fulminant Invasive Fungal Rhinosinusitis

Fulminant invasive fungal rhinosinusitis is an aggressive, destructive process most commonly affecting the immunocompromised host. Although frequently fatal, prognosis is related directly to early recognition and aggressive treatment. Various reports advocate computed tomography (CT) scanning as the study of choice in evaluating suspected invasive fungal disease, reserving magnetic resonance imaging (MRI) for select cases. Others report lack of correlation between CT and surgical or pathological findings. Our aim was to investigate the usefulness of CT and MR in the diagnosis of invasive fungal rhinosinusitis. We retrospectively reviewed four cases of biopsyproven invasive disease. Correlations between radiographic, endoscopic, and surgical findings were investigated. Rhizopus species were detected in three cases and mixed Mucor and Aspergillus species in another. Superimposed bacterial sinusitis was confirmed in all cases. CT findings were nonspecific, revealing pansinusitis; no bone destruction or intracranial extension was noted. Mild orbital cellulitis was noted in one case. Anterior rhinoscopy revealed nonviable tissue in two patients. Nasal endoscopy later confirmed tissue ischemia in a third patient, whereas a final patient had normal findings on both exams. Nonspecific findings resulted in delay of diagnosis by 48–72 hours in two patients with presumed bacterial sinusitis. MR revealed intracranial extension in two patients and better represented intraoperative findings. In conclusion, CT findings in invasive fungal rhinosinusitis may be nonspecific and underestimate extent of disease. A high index of suspicion and early endoscopic examination with biopsy are mandatory for evaluation. MRI may better represent disease progression and should be considered early.

Rare Orbital Infections ~ State of the Art ~ Part II

Infections of the orbit and periorbita are relatively frequent. Identifying unusual organisms is crucial because they can cause severe local and systemic morbidity, despite their rarity. Opportunistic infections of the orbit should be considered mainly in debilitated or immunocompromised patients. The key to successful management includes a high index of suspicion, prompt diagnosis, and addressing the underlying systemic disease. This review summarizes unusual infectious processes of the orbit, including mycobacterial, fungal, and parasitic infections, as well as their pathophysiology, symptoms, signs, and treatment.

Chronic orbital and calvarial fungal infection with Apophysomyces variabilis in an immunocompetent patient

Apophysomyces is a rare fungal organism causing rhino-orbito-cerebral mycotic infections with high morbidity and mortality, typically in immunocompetent individuals. Several cases of Apophysomyces elegans orbital disease have been reported. Herein, we report a case of Apophysomyces variabilis infection involving the orbit, sinuses, and calvarium in an immunocompetent 74-year-old woman, with a review of the literature. Unlike prior cases of A. elegans classic rhino-orbito-cerebral infection, our case included diffuse calvarial lytic lesions and overlying soft tissue nodules, but without parenchymal intracranial involvement. There was radiographic and clinical evidence of infarction of the orbital contents and cavernous sinus thrombosis. Anastomoses between the superior orbital (ophthalmic) vein and diploic veins of the calvarium are believed to be primarily responsible for the unusual mode of spread on the extradural surface of the brain. Although the patient stabilized without definitive surgical intervention, her disease slowly and intermittently progressed for over a year after presentation, requiring multiple courses of antifungal treatment.

Early Differential Diagnosis of Rhino-Orbito-Cerebral Mucormycosis and Bacterial Orbital Cellulitis: Based on Computed Tomography Findings

PURPOSE

To identify significant clinical and radiological findings that distinguish rhino-orbito-cerebral mucormycosis (ROCM) from bacterial orbital cellulitis (BOC).

METHODS

This study was retrospective, multicenter, case-control study that enrolled 34 cases; 14 cases were diagnosed with ROCM and 20 cases were diagnosed with BOC at three different tertiary hospitals between 2005 and 2013. The medical records of all 34 cases were reviewed. The initial clinical manifestations (eyelid swelling, ptosis, extraocular muscle [EOM] limitation, conjunctival injection, and chemosis) and computed tomography (CT) findings (sinus mucosal thickening, full opacification, and air-fluid level) of both diseases were compared.

RESULTS

Patients with diabetes mellitus (DM) and hypertension (HTN) showed higher incidence rates of ROCM than BOC (DM: p < 0.001, HTN: p = 0.036). ROCM cases exhibited more frequent EOM limitation than cases with BOC (100.0% vs. 66.7%, p = 0.024) but less frequent eyelid swelling (35.7% vs. 90.0%, p = 0.002). However, the incidence rates of ptosis, conjunctival injection, and chemosis exhibited no differences between the diseases. Abnormal CT findings were observed in the sinuses of all patients with ROCM, whereas 12 patients with BOC had sinus abnormalities (100.0% vs. 60.0%, p = 0.011). Thickening of the sinus mucosa was more frequent in patients with ROCM than in those with BOC (92.9% vs. 45.0%, p = 0.009). No significant differences in full opacification or air-fluid level were detected between the groups.

CONCLUSIONS

The differential diagnosis of ROCM and BOC is difficult. Nevertheless, physicians should consider ROCM when a patient with suspected orbital cellulitis presents with EOM limitation without swollen eyelids or thickening of the sinus mucosa on a CT scan.

Pathogens penetrating the central nervous system: infection pathways and the cellular and molecular mechanisms of invasion

The brain is well protected against microbial invasion by cellular barriers, such as the blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB). In addition, cells within the central nervous system (CNS) are capable of producing an immune response against invading pathogens. Nonetheless, a range of pathogenic microbes make their way to the CNS, and the resulting infections can cause significant morbidity and mortality. Bacteria, amoebae, fungi, and viruses are capable of CNS invasion, with the latter using axonal transport as a common route of infection. In this review, we compare the mechanisms by which bacterial pathogens reach the CNS and infect the brain. In particular, we focus on recent data regarding mechanisms of bacterial translocation from the nasal mucosa to the brain, which represents a little explored pathway of bacterial invasion but has been proposed as being particularly important in explaining how infection with Burkholderia pseudomallei can result in melioidosis encephalomyelitis.

Perineural spread of rhino-orbitocerebral mucormycosis caused by Apophysomyces elegans

Rhino-orbitocerebral mucormycosis (ROCM) is a fungal infection commonly affecting individuals with diabetes and those in immunocompromised states. However, infections caused by Apophysomyces elegans can involve immunocompetent individuals. The invasion pattern of cerebral mucormycosis is somewhat predictable and may occur by direct invasion or hematogenous spread. Perineural spread of the disease is unusual. Here, we report the first case of perineural extension of ROCM caused by A. elegans along the trigeminal nerve in a 25-year-old immunocompetent, nondiabetic individual.

Rhino-orbital-cerebral mucormycosis with different cerebral involvements: infarct, hemorrhage, and ophthalmoplegia

Rhino-orbital-cerebral mucormycosis is a rare but often fatal opportunistic necrotizing infection of the sinuses, orbit, and brain caused by saprophytic fungi. It usually develops in patients with diabetes or immune system deficiency. In this study, imaging features in 3 patients with rhino-orbital-cerebral mucormycosis who presented with various symptoms and different cerebral involvements are discussed. Headache, blurred vision, fever, painful ophthalmoplegia, and cranial nerve involvement were among the clinical findings. Computed tomography and magnetic resonance imaging are the best imaging methods for assessing the extent of this disease. Relatively typical but nonspecific characteristics are bone destruction, vascular invasion, and central hypointensity in the paranasal sinuses or an intracranial mass that is revealed by T(2)-weighted magnetic resonance imaging. Imaging findings include cavernous sinus involvement, cerebral infarct, and intracerebral hemorrhage. Because of the invasive and fulminant nature of rhino-orbital-cerebral mucormycosis, successful treatment seems to be based on early diagnosis and on the management of underlying immunologic problems.

Invasive sinus aspergillosis with perineural spread in an immunocompetent patient

Invasive aspergillosis of paranasal sinuses is usually seen in immunocompromised patients and is associated with a very high mortality rate. The disease is distinctly uncommon in immunocompetent patients. A rare case of invasive aspergillosis of paranasal sinus and orbit with intracranial extradural extension via perineural spread along the maxillary division of the trigeminal nerve in an immunocompetent patient is presented.

Rhinocerebral mucormycosis: perineural spread via the trigeminal nerve

We report a case of rhinocerebral mucormycosis associated with an abscess in the lateral aspect of the pons associated with perineural spread of disease via the trigeminal nerve. Contrast enhanced MRI was useful in depicting the extent of the disease and suggesting perineural spread. A pathological diagnosis of mucormycosis was established by means of rhino-orbital punch biopsy.

Epidemiology and outcome of zygomycosis: a review of 929 reported cases

BACKGROUND

Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease.

METHODS

We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described.

RESULTS

The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively).

CONCLUSIONS

Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.

Current perspectives on ophthalmic mycoses

Fungi may infect the cornea, orbit and other ocular structures. Species of Fusarium, Aspergillus, Candida, dematiaceous fungi, and Scedosporium predominate. Diagnosis is aided by recognition of typical clinical features and by direct microscopic detection of fungi in scrapes, biopsy specimens, and other samples. Culture confirms the diagnosis. Histopathological, immunohistochemical, or DNA-based tests may also be needed. Pathogenesis involves agent (invasiveness, toxigenicity) and host factors. Specific antifungal therapy is instituted as soon as the diagnosis is made. Amphotericin B by various routes is the mainstay of treatment for life-threatening and severe ophthalmic mycoses. Topical natamycin is usually the first choice for filamentous fungal keratitis, and topical amphotericin B is the first choice for yeast keratitis. Increasingly, the triazoles itraconazole and fluconazole are being evaluated as therapeutic options in ophthalmic mycoses. Medical therapy alone does not usually suffice for invasive fungal orbital infections, scleritis, and keratitis due to Fusarium spp., Lasiodiplodia theobromae, and Pythium insidiosum. Surgical debridement is essential in orbital infections, while various surgical procedures may be required for other infections not responding to medical therapy. Corticosteroids are contraindicated in most ophthalmic mycoses; therefore, other methods are being sought to control inflammatory tissue damage. Fungal infections following ophthalmic surgical procedures, in patients with AIDS, and due to use of various ocular biomaterials are unique subsets of ophthalmic mycoses. Future research needs to focus on the development of rapid, species-specific diagnostic aids, broad-spectrum fungicidal compounds that are active by various routes, and therapeutic modalities which curtail the harmful effects of fungus- and host tissue-derived factors.

Zygomycosis

Zygomycosis, an uncommon but frequently fatal mycosis caused by fungi of the class Zygomycetes, develops most commonly as an opportunistic disease. Successful therapy involves a combined approach based on early diagnosis, prompt institution of medical therapy, and extensive surgical debridement of all devitalized tissue. Given the rarity of this condition, novel therapeutic strategies have been limited and only tested on an individual basis. The use of high-dose lipid formulations of amphotericin B, prompt reversal of the underlying predisposing condition, and hyperbaric oxygen are the most common strategies that have shown potential value in the treatment of zygomycosis.

Rhino-orbital and rhino-orbito-cerebral mucormycosis

BACKGROUND

Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating infection of immunocompromised hosts. We present our experience with 19 ROCM cases and attempt to define preferred diagnostic and treatment protocols.

METHODS

All had tissue biopsies obtained studied by direct smear, histologic studies, and cultures. Imaging was obtained in 14 cases.

RESULTS

Sixteen patients presented between August and November. Six had mixed fungal infections. Seven patients had end-stage underlying disease or infection and did not undergo surgery and 4 had an indolent form of disease. Patients were treated by surgery and by amphotericin B. The overall survival was 47%.

CONCLUSIONS

ROCM may have seasonal incidence peaking in the fall and early winter. The therapeutic approach should be unchanged in cases of mixed fungal infections. Amphotericin B with aggressive debridement remains the mainstay of treatment. Early recognition and treatment are essential. A presentation and survival-dependent classification of ROCM are offered.

Rhinocerebral mucormycosis in the era of lipid-based amphotericin B: case report and literature review

Rhinocerebral mucormycosis (RCM) is an invasive fungal infection that necessitates, in most cases, aggressive surgical debridement and high cumulative, often nephrotoxic doses of amphotericin B. A 50-year-old woman with RCM was treated successfully with amphotericin B lipid complex as primary therapy. The patient previously had displayed progressive intracranial involvement and rising serum creatinine levels while receiving the conventional (nonlipid) form of amphotericin B. A literature review identified only a few cases where systemic antifungal therapy was administered, with minimal or no surgery. Our case further supports that amphotericin B lipid complex can be used as primary therapy in selected patients with RCM, without the need for surgical exenteration.

Histologic features of zygomycosis: emphasis on perineural invasion and fungal morphology

OBJECTIVE

Invasive zygomycosis is rapidly progressive and is associated with angioinvasion and infarction. Invasive disease requires emergent surgical and medical intervention. Because it is important for surgical pathologists to recognize these fungi and their preferential sites of growth, the objective of this article is to describe the fungal morphology and histopathologic findings in biopsies from patients with zygomycotic disease, with emphasis on preferential sites of fungal growth.

DESIGN

Medical record and histologic review identified 20 patients with zygomycosis. Inclusion criteria included the presence of typical ribbonlike hyphae and positive culture, a clinical history of invasive zygomycosis, or both. The histologic features of disease and the fungal morphology were assessed.

RESULTS

Fungus ball (15%), rhinocerebral (55%), and pulmonary (30%) disease were the types of disease represented. The inflammatory responses were predominantly neutrophilic (50%), predominantly granulomatous (5%), pyogranulomatous (25%), or absent (20%). Invasive disease was characterized by prominent infarcts (94%), angioinvasion (100%), and, surprisingly, prominent perineural invasion (90%) in biopsies that contained nerves for evaluation. At least rare hyphal septa were always seen (100%), and most branches (95%) varied from 45 degrees to 90 degrees.

CONCLUSIONS

As known to mycologists, zygomycetes are pauciseptate, rather than aseptate, molds. Therefore, the presence of an occasional septum is expected. Perineural invasion is a common finding in invasive zygomycosis, as are angioinvasion and infarcts. Therefore, prior to excluding the presence of these fungi in biopsies suspected to contain zygomycetes, the perineural space should be carefully examined.

Long-term survival of a patient with invasive cranial base rhinocerebral mucormycosis treated with combined endovascular, surgical, and medical therapies: case report

OBJECTIVE

Rhinocerebral mucormycosis is a clinical syndrome resulting from an opportunistic infection caused by a fungus of the order Mucorales. The prognosis of rhinocerebral mucormycosis, once considered uniformly fatal, remains poor. Even with early diagnosis and aggressive surgical and medical therapy, the mortality rate is high. We present a patient with rhinocerebral mucormycosis involving the paranasal sinuses and cranial base who experienced long-term survival after multimodality treatment. Clinical characteristics of the disease are discussed, and the literature is reviewed.

CLINICAL PRESENTATION

A 24-year-old diabetic man presented with invasive rhinocerebral mucormycosis involving the paranasal sinuses, right middle fossa, and right cavernous sinus.

INTERVENTION

The patient underwent endovascular sacrifice of the involved carotid artery and radical resection of the cranial base, including exenteration of the cavernous sinus. Reconstruction with a local muscle flap was performed. He continued to receive intravenous and intrathecal administration of antibiotics.

CONCLUSION

Long-term survival with invasive rhinocerebral mucormycosis is rare, but possible, with aggressive multimodality treatment, including carotid sacrifice for en bloc resection of the pathology, when indicated.

Lung cancer, proptosis, and decreased vision

A 48-year-old man presented to the emergency department with a 3-day history of decreased vision in a painful proptotic right eye. The patient was being treated with chemotherapy and radiation for non-small cell lung carcinoma. Examination showed visual acuity of hand motions, decreased motility, and an afferent pupillary defect on the right, consistent with an orbital apex syndrome. Neuroimaging revealed "dirty" orbital fat and no paranasal sinus disease. Orbital biopsy initially showed only fibrosis; however, on subsequent biopsies, nonseptate hyphae later identified as mucormycosis was recovered. The patient survived with exenteration and systemic amphotericin B.

Endoscopic sinus surgery for rhinocerebral mucormycosis

Rhinocerebral mucormycosis is a fulminant, often fatal, disease. Aggressive surgical debridement has been considered an important part of treatment. Traditionally, an external or transantral approach has been the classic method. Recently, endoscopic sinus surgery (ESS) has been tried on several occasions to reach the goal of radical resection. Since 1991, ESS has been used to treat 9 rhinocerebral mucormycosis patients in our department. Among them, ESS was the only surgical procedure in six patients. The other three patients were treated by ESS combined with a transantral procedure. As a result, eight patients (88.9%) have survived the disease. One patient died 5 days after ESS because of an internal carotid artery occlusion. We conclude that ESS can be used to treat rhinocerebral mucormycosis alone or in combination with the traditional surgical procedures. It has the advantage of less operative morbidity and greater operative accuracy.

Long-term survival in rhinocerebral mucormycosis. Case report

Mucormycosis refers to a group of rapidly progressive infections caused by fungi belonging to the order Mucorales. Infection most often develops in individuals with immunological or metabolic compromise, although patients without underlying abnormalities have been affected. Specific clinical manifestations are associated with various predisposing factors. Rhinocerebral mucormycosis is the most common form and most frequently develops in individuals with poorly controlled diabetes mellitus. The extent of anatomical involvement and clinical course are unpredictable, depending on the intrinsic factors of the host. Over the past 20 years the prognosis for patients with rhinocerebral mucormycosis, once considered to be a uniformly fatal disease, has improved. Coordinated medical and surgical treatment, including rapid diagnosis, the advent of systemic antifungal agents, aggressive surgical debridement, and control of the underlying disease process, have been credited with its successful management. The range of survival rates recorded with the regimen of combined therapies is wide because the number of patients reported is limited and anatomical involvement is diverse. Survival with intracerebral abscess is rare. The authors describe the successful management of a patient who developed a bifrontal fungal abscess during treatment for rhinocerebral mucormycosis associated with ketoacidosis and diabetes mellitus. The patient remains without radiographic or clinical evidence of infection more than 2 years after treatment. The authors review the characteristic clinical, radiographic, and pathological features of previously reported infections and emphasize the importance of early detection and aggressive treatment in the management of this frequently fulminant and fatal disease.

Vasculitis owing to infection

Infections are a recognized cause of secondary vasculitis. A variety of pathogens have a propensity to involve blood vessels. Vasculitis, non-vasculitic vasculopathy, and mycotic aneurysms lead to infarction and hemorrhage of nervous system tissue. Treatment of infection-related vasculitis should include appropriate antimicrobial therapy directed against the offending pathogen, and appropriate management of cerebrovascular complications.

Computed tomography and magnetic resonance diagnosis of allergic fungal sinusitis

The objective of this study was to describe CT and MR findings in patients with allergic fungal sinusitis (AFS). CT and MR images were examined from 10 patients with histologically proven AFS. All patients demonstrated CT evidence of central sinus high attenuation and T2-weighted MR signal void corresponding to surgically proven areas of thick inspissated allergic mucin. AFS is a distinct clinical entity with a highly specific radiographic appearance based on CT and MRI.

Infectious emergencies in patients with diabetes mellitus

Although it remains controversial as to whether diabetics have an overall increased incidence of infection as compared to nondiabetics, several potentially life-threatening infections do appear to be uniquely associated with diabetes. These infections generally occur in older diabetics with less than optimal glucose control. For each entity, selected symptoms and signs may suggest the diagnosis but confirmation of via tissue biopsy with culture and histopathology or radiography is usually necessary. Management typically require both antimicrobial treatment and surgery.

Survival factors in rhino-orbital-cerebral mucormycosis

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

Renal mucormycosis: computerized tomographic findings and their diagnostic significance

Isolated renal involvement by mucormycosis has been reported rarely in immunocompromised individuals. We describe four patients with mucormycosis confined to the kidneys, three of whom did not exhibit any predisposing factors. Only one patient had acute viral hepatitis with fulminant hepatic failure as the preceding disease. Two patients presented with oliguric renal failure of undetermined etiology and investigations revealed bilateral extensive involvement of the kidneys. Computerized tomography showed diffuse enlargement of the kidneys and multiple low-density areas. Treatment included systemic amphotericin B therapy in all four patients and nephrectomy in three patients. Two patients recovered completely. Our experience emphasizes the need for a high index of suspicion and recognition of computed tomographic scan appearances for making a prompt diagnosis. Early surgical intervention and systemic antifungal therapy are necessary for survival in this life-threatening condition.

MR imaging in rhinocerebral and intracranial mucormycosis with CT and pathologic correlation

Three cases of mucormycosis, two in diabetics and one in an intravenous drug abuse patient, are presented. Magnetic resonance imaging proved to be useful in all cases, as was computed tomography. In one case, extremely low signal was detected from the fungal mass. It is surmised that this appearance was a result of high concentrations of iron and manganese. The low-signal area simulated air in paranasal sinuses; however, CT displayed a mildly enhancing soft tissue mass and allowed the correct diagnosis to be made. In another patient, pontine infarction was demonstrated by MR. In the third case the MR findings of mucormycosis involving the basal ganglia are shown and correlated with CT. Subsequent imaging studies demonstrated reduction of the mass, corresponding to clinical improvement.

Rhinocerebral mucormycosis: use of liposomal amphotericin B

Rhinocerebral mucormycosis is a rare but often fatal condition characterized by an aggressive necrotizing infection spreading from the nose to the paranasal sinuses, orbit and hence to the central nervous system. A case is reported in which a diabetic male with advanced mucormycosis was successfully treated by a combination of surgery, supportive therapy and liposomal amphotericin B. Liposomal delivery allows the drug to be both less toxic and more effective, and this is the first reported case of its use in rhinocerebral mucormycosis.

Rhinocerebral mucormycosis: management and survival after carotid occlusion

Rhinocerebral mucormycosis is a rare but often fatal fungal infection. We present 2 patients with mucormycosis complicated by internal carotid artery thrombosis. Magnetic resonance imaging was superior to computed tomography in localizing the pathological process. Subtotal resection of devitalized tissue and intravenous amphotericin B therapy resulted in a successful outcome for both patients. Prompt recognition of this disorder by using modern diagnostic and therapeutic modalities promises to improve survival rates.