Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

Rhino-orbital-cerebral mucormycosis

I-Wen Chen and Cheng-Wei Lin
CMAJ April 23, 2019 191 (16) E450; DOI: https://doi.org/10.1503/cmaj.181210
I-Wen Chen
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Cheng-Wei Lin
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF
Loading

This article has a correction. Please see:

  • Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection - May 25, 2020

A 64-year-old woman of Asian descent presented to the emergency department with an initial diagnosis of hyperosmolar hyperglycemic state. She had type 2 diabetes mellitus and cervical cancer, and had received chemotherapy with cisplantin 3 days before presentation.

On being admitted to hospital, the patient experienced sudden-onset blindness, and chemosis and proptosis of the left eye, accompanied by low-grade fever (38.2°C). Postcontrast T1-weighted magnetic resonance imaging (MRI) showed hypointensity in her left frontal lobe and enhancement around her left optic nerve, indicating perineuritis (Figure 1A). In addition, on diffusion-weighted imaging, hyperintensity in her left optic nerve (Appendix 1A, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.181210/-/DC1) with decreased apparent diffusion coefficient (Appendix 1B) indicated acute infarction. The presence of a black turbinate sign in her left nasal cavity, and an air-fluid level over her left maxillary sinus was consistent with infective sinusitis (Figure 1B).

Figure 1:
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1:

(A) Coronal T1-weighted contrast-enhanced magnetic resonance image (MRI) showing hypointensity in the left frontal lobe of the brain of a 64-year-old woman, indicating ischemic infarction, enhancement around, rather than within, the left optic nerve with doughnut appearance (arrow), indicating perineuritis, and mucosal thickening in the left maxillary sinus (arrowhead). (B) Axial view showing lack of enhancement of the left nasal turbinate (black turbinate sign, arrow) and an air-fluid level over her left maxillary sinus (arrowhead), indistinguishable from that seen in bacterial sinusitis.

We performed urgent surgical débridement, noting eschar formation over the patient’s left nasal cavity with bone erosion (Appendix 1C). Results from histologic examination showed broad and nonseptated fungal hyphae at 90° angles, confirming mucormycosis. Despite treatment with amphotericin B, the patient died 2 weeks later.

Mucormycosis is an uncommon but fatal fungal infection, found in 10% of all fungal infections at autopsy and primarily affecting patients who are immunocompromized, especially those with diabetes.1 Early diagnosis and treatment are crucial for survival. The sinuses are most commonly affected, and subsequent rhino-orbital-cerebral mucormycosis is closely associated with diabetes.1 A clinical presentation of orbital swelling, black nasal discharge, visual defect, proptosis and headache suggests rhinoorbital-cerebral mucormycosis.1 Black turbinate sign represents devitalized mucosa leading to a hypointense mucosal appearance on MRI. There is a previous report of a patient who developed nerve infarction 2 weeks after being diagnosed with mucormycosis; 2 optic neuritis and infarction as the initial presentation of mucormycosis is uncommon.3 Contrast-enhanced MRI can show the spread of perineural infection as high signal intensity along the nerve3 and is more valid than computed tomography.1

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • The authors have obtained consent from the patient’s daughter.

References

  1. ↵
    1. Petrikkos G,
    2. Skiada A,
    3. Lortholary O,
    4. et al
    . Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis 2012;54(Suppl 1):S23–34.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Mathur S,
    2. Karimi A,
    3. Mafee MF
    . Acute optic nerve infarction demonstrated by diffusion-weighted imaging in a case of rhinocerebral mucormycosis. AJNR Am J Neuroradiol 2007;28:489–90.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Alsuhaibani AH,
    2. Al-Thubaiti G,
    3. Al Badr FB
    . Optic nerve thickening and infarction as the first evidence of orbital involvement with mucormycosis. Middle East Afr J Ophthalmol 2012;19:340–2.
    OpenUrlPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 191 (16)
CMAJ
Vol. 191, Issue 16
23 Apr 2019
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Rhino-orbital-cerebral mucormycosis
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Rhino-orbital-cerebral mucormycosis
I-Wen Chen, Cheng-Wei Lin
CMAJ Apr 2019, 191 (16) E450; DOI: 10.1503/cmaj.181210

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Rhino-orbital-cerebral mucormycosis
I-Wen Chen, Cheng-Wei Lin
CMAJ Apr 2019, 191 (16) E450; DOI: 10.1503/cmaj.181210
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Azathioprine-induced severe anemia potentiated by the concurrent use of allopurinol
  • Schwannoma of the tongue
  • “Superscan” in diffusion-weighted imaging with background body suppression magnetic resonance imaging
Show more Practice

Similar Articles

Collections

  • Sections
    • Clinical Images
  • Topics
    • Infectious diseases
    • Emergency medicine

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire