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Kanaujiya R, Paruthi C, M J A, Sood K, Gupta S, Sharma A. Orbital compartment syndrome in orbital mucormycosis: spot the threat through radiologist's eye. Emerg Radiol 2025; 32:217-224. [PMID: 39939557 DOI: 10.1007/s10140-025-02318-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Accepted: 01/31/2025] [Indexed: 02/14/2025]
Abstract
PURPOSE To illustrate the imaging findings of orbital compartment syndrome (OCS) in patients with orbital mucormycosis and to identify the red flag signs on imaging for prompt diagnosis and timely intervention. METHODS We conducted a retrospective analysis of CT and MRI scans from patients diagnosed with sino-nasal mucormycosis within three months of a confirmed COVID-19 infection. Microbiologically proven cases of mucormycosis were included. Images were analysed for: Route of spread; proptosis; tenting of globe, Retro-orbital fat/extraocular muscle (EOM) nonenhancement; Intra-orbital abscess, superior ophthalmic vein (SOV) thrombosis, stretching/thickening/enhancement/diffusion restriction of optic nerve, orbital coat, and EOM. Descriptive statistics were elaborated in the form of mean/standard deviations for continuous variables and frequencies and percentages for categorical variables. RESULTS Out of 138 patients with mucormycosis, 49 had orbital involvement, OCS was present in 16 orbits. The mean age was 48.6 years with M: F of 2.75:1. Adjacent sinuses were involved in all patients. Spread along nerves and nasolacrimal duct was seen in 94% patients. Globe tenting was seen in all and thickening/coat enhancement in 53.3%. Optic nerve (ON) was thickened in 87.5%, diffusion restriction of ON and EOM in 78.5% cases. Non enhancement of retro-orbital fat was seen in 50% and intra-orbital abscess in 62.5% cases. CONCLUSIONS OCS is a vision-threatening orbital emergency, leading to OIS and permanent blindness, if not managed promptly. Imaging features that warrant immediate clinical/ surgical intervention to avoid permanent loss of vision are distorted globe, posterior tenting of the globe, stretching of the optic nerve, non-enhancement of retro-bulbar fat and extra-ocular muscles (EOMs).
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Affiliation(s)
- Reeta Kanaujiya
- Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | - Charu Paruthi
- Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, 110029, India.
| | - Aravind M J
- Sharp Sight Eye Hospital, Metro Pillar Number 78, A6/A7, Vikas Marg, Opp. Preet Vihar, Block A, Swasthya Vihar, New Delhi, 110092, India
| | - Komal Sood
- Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | - Swarna Gupta
- Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | - Anuradha Sharma
- Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, 110029, India
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Liang M, Xu J, Luo Y, Qu J. Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review. Ann Med 2024; 56:2396570. [PMID: 39221718 PMCID: PMC11370679 DOI: 10.1080/07853890.2024.2396570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/25/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024] Open
Abstract
AIM This review aims to summarize the epidemiology, etiology, pathogenesis, clinical manifestations, and current diagnostic and therapeutic approaches for mucormycosis. The goal is to improve understanding of mucormycosis and promote early diagnosis and treatment to reduce mortality. METHODS A comprehensive literature review was conducted, focusing on recent studies and data on mucormycosis. The review includes an analysis of the disease's epidemiology, etiology, and pathogenesis, as well as current diagnostic techniques and therapeutic strategies. RESULTS Mucormycosis is increasingly prevalent due to the growing immunocompromised population, the COVID-19 pandemic, and advances in detection methods. The pathogenesis is closely associated with the host immune status, serum-free iron levels, and the virulence of Mucorales. However, the absence of typical clinical manifestations complicates diagnosis, leading to missed or delayed diagnoses and higher mortality. CONCLUSION An enhanced understanding of the epidemiology, pathogenesis, and clinical presentation of mucormycosis, along with the adoption of improved diagnostic and therapeutic approaches, is essential for reducing mortality rates associated with this opportunistic fungal infection. Early diagnosis and prompt treatment are critical to improving patient outcomes.
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Affiliation(s)
- Mei Liang
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jian Xu
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanan Luo
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Junyan Qu
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Channegowda C, Balaraj S, Reddy HN, Patil SB, R SPD, Uthappa T, R. SK. The Outcome of Endoscopic Sinus Surgery for Orbital Apex Syndrome Secondary to Sinusitis in a Tertiary Care Center-Our Experience Over 10 Years. Turk Arch Otorhinolaryngol 2024; 62:7-13. [PMID: 39257036 PMCID: PMC11587521 DOI: 10.4274/tao.2024.2023-12-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/05/2024] [Indexed: 09/12/2024] Open
Abstract
Objective Orbital apex syndrome (OAS) is a rare condition with multiple cranial nerve involvement caused by varied etiologies. It is not only a threat to the patient's vision but also life-threatening due to the intracranial spread of infection, if not diagnosed early and treated accurately. To study the outcome of endoscopic sinus surgery (ESS) for OAS secondary to sinusitis concerning resolution of ptosis, improvement of ophthalmoplegia, visual prognosis, intracranial spread of infection, and mortality. Methods A retrospective review of patients with OAS secondary to sinusitis who underwent ESS from 2011 to 2021 was tabulated and analyzed. Results Twenty-seven patients (mean age: 55.11+/-16 years; male 62%) were included in this study. At presentation, blurring of vision (81%), headache (66%), diplopia (63%) ptosis (63%) were the most common symptoms, and ophthalmoplegia (100%) was the most common sign. Five patients had no perception of light and the rest had various degrees of vision impairment. The most common etiopathology of sinusitis was fungal sinusitis (12 mucormycosis and four aspergillus). The final visual prognosis at three months follow-up post-ESS showed vision stabilization (no improvement or worsening) in 13 (48%) patients, improvement in seven (26%) patients, and vision deterioration in two (7%) patients. There was a significant improvement in ptosis (70%) and ophthalmoplegia (85%). There was no intracranial spread of infection or recurrence with a mortality rate of 3.7% (one patient). Conclusion ESS coupled with appropriate antimicrobials effectively treats OAS secondary to sinusitis with decreased morbidity and mortality.
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Affiliation(s)
- Chandrakiran Channegowda
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Soujanya Balaraj
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Harshavardhan N. Reddy
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Sanjay B. Patil
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Surya Prakash D R
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Trupthi Uthappa
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
| | - Sumanth K. R.
- Department of Otorhinolaryngology and Head and Neck Surgery Ramaiah Medical College, Bengaluru, India
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Chen CH, Chen JN, Du HG, Guo DL. Isolated cerebral mucormycosis that looks like stroke and brain abscess: A case report and review of the literature. World J Clin Cases 2023; 11:1560-1568. [PMID: 36926404 PMCID: PMC10011993 DOI: 10.12998/wjcc.v11.i7.1560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/07/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Cerebral mucormycosis is an infectious disease of the brain caused by fungi of the order Mucorales. These infections are rarely encountered in clinical practice and are often misdiagnosed as cerebral infarction or brain abscess. Increased mortality due to cerebral mucormycosis is closely related to delayed diagnosis and treatment, both of which present unique challenges for clinicians.
CASE SUMMARY Cerebral mucormycosis is generally secondary to sinus disease or other disseminated disease. However, in this retrospective study, we report and analyze a case of isolated cerebral mucormycosis.
CONCLUSION The constellation of symptoms including headaches, fever, hemiplegia, and changes in mental status taken together with clinical findings of cerebral infarction and brain abscess should raise the possibility of a brain fungal infection. Early diagnosis and prompt initiation of antifungal therapy along with surgery can improve patient survival.
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Affiliation(s)
- Cai-Hong Chen
- Department of Neurology, Hangzhou Ninth People's Hospital, Hangzhou 311225, Zhejiang Province, China
| | - Jing-Nan Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, Zhejiang Province, China
| | - Hang-Gen Du
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, Zhejiang Province, China
| | - Dong-Liang Guo
- Department of Neurology, Hangzhou Ninth People's Hospital, Hangzhou 311225, Zhejiang Province, China
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Sidhu JK, Wan Hitam WH, Ahmad Tajudin LS. Presumptive Rhino-Orbital Mucormycosis Secondary to Corticosteroid Therapy in a Diabetic Patient With COVID-19 Infection. Cureus 2023; 15:e35199. [PMID: 36968851 PMCID: PMC10032174 DOI: 10.7759/cureus.35199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 02/22/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to the widespread use of steroids as a life-saving measure. In patients with preexisting diabetes, the therapeutic use of steroids coupled with poorly controlled sugar has led to a surge of mucormycosis. We report a rare case of orbital apex syndrome secondary to mucormycosis post-COVID-19. A 43-year-old female with poorly controlled diabetes mellitus presented with right eye complete ptosis one week post-recovery from COVID-19 infection. During COVID-19 hospitalization, she received a course of dexamethasone. The visual acuity of the right eye was 6/60. She had complete ophthalmoplegia and diplopia in all gazes. There was a positive relative afferent pupillary defect (RAPD) and reduced optic nerve function test in the right eye. MRI showed right ethmoid sinusitis with possible extension to the right orbit and the presence of right perineural optic nerve enhancement. The nasal scope revealed fungal-like thick mucopurulent discharge at the middle meatus. She was clinically diagnosed with rhino-orbital mucormycosis and was started on antifungal for six weeks. Her overall condition improved with 6/6 visual acuity and minimum residual ophthalmoplegia. In conclusion, corticosteroid treatment for COVID-19 infection in diabetic patients causes poor glycemic control and immunosuppression that can lead to secondary infections such as rhino-orbital mucormycosis.
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Patnaik A, Sharma B, Ahmad R, Kumar A, Chitrotpala R, Gupta M. A Case of Bilateral Central Retinal Artery Occlusion in a Post-COVID Rhino-Orbital-Cerebral Mucormycosis Patient. Cureus 2021; 13:e20062. [PMID: 35003938 PMCID: PMC8723730 DOI: 10.7759/cureus.20062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 01/22/2023] Open
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Sreshta K, Dave TV, Varma DR, Nair AG, Bothra N, Naik MN, Sistla SK. Magnetic resonance imaging in rhino-orbital-cerebral mucormycosis. Indian J Ophthalmol 2021; 69:1915-1927. [PMID: 34146057 PMCID: PMC8374747 DOI: 10.4103/ijo.ijo_1439_21] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Coronavirus disease-associated mucormycosis (CAM) is an established clinical entity in India. In the past 4 months, there has been a sharp upsurge in the number of CAM cases in most parts of the country. Early diagnosis can be lifesaving. Magnetic resonance imaging (MRI) imaging remains the corner stone of management in patients with ROCM. This review discussed the utility of MRI imaging in ROCM with an emphasis on the ideal MRI protocol in a suspected case of ROCM, the pathways of spread of infection, the classic diagnostic features, MRI for staging of the disease, MRI for prognostication, MRI for follow up, and imaging features of common differentials in ROCM. The pit falls of MRI imaging and a comparison of CT and MRI imaging in ROCM are discussed. The clinical interpretation of areas of contrast uptake and those of necrosis and its relevance to treatment are discussed. This review aims to familiarize every member of the multidisciplinary team involved in managing these patients to be able to interpret the findings on MRI in ROCM.
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Affiliation(s)
- Kanduri Sreshta
- Department of Neuroradiology, Citi Neuro Centre, Hyderabad, Telangana, India
| | - Tarjani Vivek Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Dandu Ravi Varma
- Department of Neuroradiology, Citi Neuro Centre, Hyderabad, Telangana, India
| | - Akshay Gopinathan Nair
- Aditya Jyot Eye Hospital, Mumbai; Advanced Eye hospital and Institute, Navi Mumbai, India
| | - Nandini Bothra
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Milind N Naik
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
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Saldanha M, Reddy R, Vincent MJ. Title of the Article: Paranasal Mucormycosis in COVID-19 Patient. Indian J Otolaryngol Head Neck Surg 2021; 74:3407-3410. [PMID: 33903850 PMCID: PMC8060684 DOI: 10.1007/s12070-021-02574-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/17/2021] [Indexed: 12/24/2022] Open
Abstract
There have been a variety of complications reported during and post- COVID infection. Recently, there has been an increase in sporadic cases of paranasal sinus mucormycosis in COVID- 19 patients. We report a case of COVID- 19 patient diagnosed to have orbital apex syndrome secondary to mucormycosis of nose and paranasal sinus requiring emergency endoscopic sinus surgery. Appropriate use of personal protective equipment and safety precautions taken by health care workers prevented the spread of the virus during surgery.
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Affiliation(s)
- Marina Saldanha
- Department of Otorhinolaryngology and Head and Neck Surgery, K.S.Hegde Medical Academy, NITTE University, Mangalore, Karnataka 575018 India
| | - Rashmitha Reddy
- Department of Otorhinolaryngology and Head and Neck Surgery, K.S.Hegde Medical Academy, NITTE University, Mangalore, Karnataka 575018 India
| | - Mark Jittu Vincent
- Department of Otorhinolaryngology and Head and Neck Surgery, K.S.Hegde Medical Academy, NITTE University, Mangalore, Karnataka 575018 India
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Abstract
Fungal infections of the orbit can lead to grave complications. Although the primary site of inoculation of the infective organism is frequently the sinuses, the patients can initially present to the ophthalmologist with ocular signs and symptoms. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. Ophthalmologists should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of this invasive sino-orbital infection. In this review, relevant clinical, microbiological, and imaging findings are discussed along with the current consensus on local and systemic management. We review the recent literature and provide a comprehensive analysis. In the immunocompromised, as well as in healthy patients, a high index of suspicion must be maintained as delay in diagnosis of fungal pathology may lead to disfiguring morbidity or even mortality. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly oral voriconazole and topical amphotericin B, may be beneficial in selected patients.
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Affiliation(s)
- Bipasha Mukherjee
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Nirav Dilip Raichura
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Md Shahid Alam
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
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Abstract
Ocular or eye pain is a frequent complaint encountered not only by eye care providers but neurologists. Isolated eye pain is non-specific and non-localizing; therefore, it poses significant differential diagnostic problems. A wide range of neurologic and ophthalmic disorders may cause pain in, around, or behind the eye. These include ocular and orbital diseases and primary and secondary headaches. In patients presenting with an isolated and chronic eye pain, neuroimaging is usually normal. However, at the beginning of a disease process or in low-grade disease, the eye may appear "quiet," misleading a provider lacking familiarity with underlying disorders and high index of clinical suspicion. Delayed diagnosis of some neuro-ophthalmic causes of eye pain could result in significant neurologic and ophthalmic morbidity, conceivably even mortality. This article reviews some recent advances in imaging of the eye, the orbit, and the brain, as well as research in which neuroimaging has advanced the discovery of the underlying pathophysiology and the complex differential diagnosis of eye pain.
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