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Brain & Heart Surviving rhino-orbital-cerebral mucormycosis

uncontrolled diabetes is commonly associated with documentation was unavailable. On examination, the
ROCM, a condition that has become more prevalent due patient exhibited a dilated and fixed left pupil, conjunctival
to the increasing incidence of diabetes in our society . chemosis, and periorbital edema.
2-4
Diverse vulnerabilities in host immunity result in varying Imaging tests revealed a left temporal hypodensity on
degrees of organ involvement and clinical presentations . contrast computed tomography (CT) (Figure 1C), while
5-7
The manifestation of ROCM in COVID-19 patients contrast magnetic resonance imaging (MRI) demonstrated
without traditional risk factors is now evident. Early smooth, regular wall rim enhancement (Figure 1D) with
diagnosis and intervention are crucial to combat the diffusion restriction (Figure 1E), indicating abscess
aggressive and fulminant nature of this disease and the formation. The abscess extended into the sphenoethmoidal
overlapping symptoms with bacterial facial or orbital air sinuses, gangliocapsular area, and retroorbital region
cellulitis, which pose a diagnostic challenge . A high index (Figure 1F), leading to the final diagnosis of stage IV
8
of clinical suspicion is vital, and a definitive diagnosis ROCM). An ear swab smear confirmed the presence of
relies on the presence of non-septate broad hyphae with aseptate hyphae with right-angle branching, identifying the
right-angle branching in potassium hydroxide mounts, pathogen as mucor. Subsequently, the patient underwent left
lactophenol cotton blue mounts, and histopathological orbital modified lid-sparing exenteration, resulting in the
examinations . formation of a fistula (Figure 1G). Despite this intervention,
8
The primary aim of reporting this case was to illustrate the patient’s condition continued to deteriorate, leading to
the significant burden experienced by the patient, including agitation and altered mental status. Consequently, a left
the challenges endured by the patient during multiple temporo-parietal craniotomy with abscess excision and
surgeries, serial complications, psychological distress augmentation duroplasty was performed. Post-operative
resulting from living with a ghastly face, mental anguish contrast CT revealed satisfactory results (Figure 1H). The
due to social repulsion, the torment of separation from his biopsy result was suggestive of mucormycosis. Following
spouse, and the financial and social strain on his caretaker. surgery, the patient underwent hemimaxillectomy of the
The secondary aims included reflecting the aggressive and left maxilla due to disease progression. Despite medical
challenging nature of the disease, which makes it typically interventions, the patient was discharged with a disfigured
troublesome to recognize and extremely challenging to face (Figure 2A), significantly affecting his personal and
treat, evaluating the radicality of surgical debridement, social life. In addition, he experienced a single episode of
highlighting the role of staged reconstruction surgeries, generalized tonic-clonic seizures, prompting the escalation
and signifying the importance of multidisciplinary of antiepileptic medication.
teamwork. 6 months later, the patient experienced another
seizure episode, necessitating the addition of a second
2. Case presentation antiepileptic drug. However, he subsequently presented
A 38-year-old patient presented with pain, redness, with a bogie swelling over the left temporal region, along
swelling, ptosis, and vision loss in his left eye over the past with intermittent pus discharge from the previous surgical
20 days before seeking medical consultation (Figure 1A). site (Figure 2B). Imaging revealed bone flap osteomyelitis
He had a history of left upper molar tooth extraction and an epidural pus collection, necessitating neurosurgical
5 days before symptom onset and had experienced a past intervention and a tracheostomy due to microaspirations
COVID-19 infection without corticosteroid treatment from palatal perforation (Figure 2C). Sutures were removed
2 months earlier. The patient reported no history of 10-day post-surgery, and the patient was discharged
diabetes mellitus or other chronic medical conditions. (Figure 2D).
Initial clinical suspicion pointed toward maxillary and Subsequently, the reconstruction phase began to
sphenoethmoidal sinusitis with involvement of the medial improve the cosmetic appearance of the patient’s face.
orbital wall, leading to orbital cellulitis. The left orbitonasolabial fistula repair and debridement
Broad-spectrum antibiotics were initiated, but 4-day were performed by the plastic surgery team a couple
post-admission, a necrotic black ulcerative patch appeared of months after the previous surgery. While planning
along the left nasolabial fold (Figure 1B), indicating for reconstructive flap cover surgery during the same
zygomycete-related periarteritis, vascular thrombosis, admission, the patient developed a maggot infection at the
infarction, and angioinvasion. Intravenous amphotericin apex of the orbit (Figure 2E). Contrast MRI of the brain,
therapy was promptly initiated. Before presentation at our orbit, and paranasal sinuses revealed mucosal thickening
facility, the patient had undergone functional endoscopic of the left sphenoethmoid and frontal air sinus with
sinus surgery (FESS) elsewhere, although the relevant cavernous sinus infiltration and carotid artery encasement

Volume 2 Issue 2 (2024) 2 doi: 10.36922/bh.2083