Rapidly Progressive Rhino-orbito-cerebral Mucormycosis Complicated with Unilateral Internal Carotid Artery Occlusion: A Case Report

Abstract

Rhinocerebral mucormycosis is an acute fulminant opportunistic fungal infection usually seen in diabetic or immunocompromised patients. The fungi that cause mucormycosis inoculate the nasal mucosa and may spread to the paranasal sinuses, orbit, and brain. Our patient initially presented with mild ethmoid sinusitis. At that time, brain MRI and contrast-enhanced MR angiography were grossly normal. However, aggravation of sinusitis with extension to the right orbit and anterior cranial fossa rapidly developed within two months. Moreover, an occlusion of the right internal carotid artery was combined. We report a case of a pathologically-proven rhino-orbital-cerebral mucormycosis with serial follow-up imaging for over one year.

Keywords: Carotid artery, Internal; Fungal sinusitis; Mucormycosis.

Fig. 1

A. Axial CT images on bone window setting show bone destruction of the frontal bone adjacent to the frontal sinus, anterior ethmoid sinus wall, and cribriform plate with opacification of the frontal and ethmoid sinuses. B. Coronal CT image on the soft tissue window setting shows fluid or soft tissue density lesion in the left maxillary and right anterior ethmoid sinuses, with extension of the inflammation into the superomedial portion of the right orbit, between the superior rectus and medial rectus muscles and no evidence of involvement of the optic nerve. C. T2-weighted images demonstrate heterogeneous high signal intensity in the ethmoid sinus. Note also the lack of a flow void with high signal intensity in the carvenous portion of the right internal carotid artery. D. Time-of-flight MR angiography shows occlusion of the right internal carotid artery (ICA). E. Right common carotid angiography shows occlusion of the right proximal ICA at cervical segment. F. Postoperative follow-up brain MRI obtained at 6 months after the operation. No signal void of the right cavernous ICA is suggestive of a right ICA occlusion. Note also the bulging contour of the right cavernous sinus, probably resulting from thrombophlebitis.