Rhino-orbital Mucormycosis Manifesting as Orbital Apex Syndrome with CRAO in An Immunocompetent Patient

Abstract

Rhino-orbital mucormycosis (ROM) is an uncommon opportunistic infection affecting immunocompromised individuals. Poorly controlled diabetes mellitus is the commonest predisposing factor. A 42-year-old female with well controlled diabetic status, presenting with orbital apex syndrome (OAS) and Central Retinal Artery Occlusion (CRAO) is discussed in this report. There was no evidence of cellulitis, necrotic eschar or facial palsy. There were no features suggesting immunosuppression. The biochemical parameters including blood sugar and electrolytes were normal. Serology for HIV was negative. MRI showed pan sinusitis with thickening and enhancement of extraocular muscles. Urgent debridement of paranasal sinuses was done. Histopathological examination disclosed broad based, filamentous, aseptate hyphae suggestive of mucormycosis. Prompt treatment with systemic Amphotericin B and debridement of sinuses resulted in a favourable outcome. Mucormycosis presents with a constellation of clinical features including ophthalmoplegia, proptosis, ptosis, visual loss, chemosis, nasal discharge, abducens nerve palsy, palatal necrosis, cerebral involvement, hemiparesis and eye lid gangrene. The coexistence of sinus disease with OAS in a diabetic patient should trigger a vigilant search for a fungal etiology, despite the absence of immunosuppression. Microbiological culture may yield negative results and histopathological examination is mandatory. This report emphasizes the rare occurrence of ROM in an immunocompetent diabetic patient with good metabolic control. Early diagnosis and a multidisciplinary approach with intravenous antifungals, adequate sinus drainage and surgical debridement can greatly reduce the morbidity and mortality.

SARS-CoV-19-associated Rhino-orbital and cerebral mucormycosis: clinical and radiological presentations

“…Rhino-oculo-cerebral mucormycosis (ROCM), an uncommon disorder, denotes fungal infection of the nasal and paranasal cavities, eyes, and brain with spores of Mucor, Rhizopus, Cunninghamela, Lichthemia , and Apophysomyces . 1 Once the spores lodge in the nasal mucosa leading to necrosis, local symptoms occur in the form of nasal stuffiness and sometimes, a bloody discharge. The fungus is highly angio-invasive and it spreads from the nose to the paranasal sinuses, orbits, cavernous sinuses, meninges, and brain.…”

A rare case of rhino-orbito-maxillary mucormycosis having no common signs and laboratory findings but no visible morbidity

“…The mucor produces spores which rupture, get dispersed, and become airborne. People get infected after getting exposed to fungal spores [4].…”

“…The prevalence of COVID-19-associated mucormycosis (CAM) in India was 0.27% among patients managed in the hospital ward and 1.6% among patients managed in ICUs [5]. However, there was a 2.1-fold rise in mucormycosis cases since 2020 as compared to 2019, and research suggests that the increase is attributable to the COVID pandemic, hence the name CAM [4,5].…”