Lethargy and vision loss: successful management of rhinocerebral mucormycosis

Abstract

Rhinocerebral mucormycosis (RCM) is an angioinvasive fungal infection most often caused by Rhizopus oryzae It is usually associated with an underlying risk factor and is associated with a poor prognosis. There are no consensus guidelines on the optimal management of this aggressive disease; most management decisions are based on case reports and expert opinion. We report a successfully managed case of RCM in an insulin-dependent diabetic, initially presenting with a change in mental status, rapidly progressing to complete right eye blindness and ophthalmoplegia and complicated by multiple cerebral infarctions and abscesses. We describe the diagnostic approach and various therapeutic interventions undertaken to successfully manage our patient.

Figure 1

Examination of the right eye showing evidence of proptosis and ptosis with evidence of cellulitis involving the upper and lower eyelids.

Figure 2

Examination of the right pupil showing evidence of mydriasis.

Figure 3

CT angiography of the brain showing a total occlusion of the middle portion of the right ophthalmic artery.

Figure 4

(A) Endoscopic examination of the right nasal cavity prior to surgical debridement revealing mycelia and necrotic mucosa. (B) Endoscopic examination following surgical debridement of the nasal mucosa.

Figure 5

Gram stain of the tissue obtained during surgical debridement revealing thick, aseptate fungal hyphae branching at obtuse angles.

Figure 6

(A) MRI of the brain showing T2 abnormalities involving the right anterior medial temporal lobe, lower midbrain, lateral pons, middle cerebellar peduncle and scattered in the right cerebellar hemisphere. (B) Corresponding diffusion weighted imaging (DWI) signal abnormalities in the specified regions consistent with acute infarcts.

Figure 7

Contrast-enhanced MRI of the brain showing large rim-enhancing collections with regions of internal restricted diffusion, consistent with parenchymal abscesses in the right anterior medial temporal lobe and the right cerebellum extending to the brainstem.