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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1876-1877

Anterior Cavernous and Internal Carotid Artery Thrombosis - A Rare Complication of Rhino-orbito-cerebral Mucormycosis


1 Department of Neurology, Dr. RML Hospital, New Delhi, Tamil Nadu, India
2 Department of Microbiology, Dr. RML Hospital, New Delhi, Tamil Nadu, India
3 Department of Physiology, Dr. RML Hospital, New Delhi, Tamil Nadu, India

Date of Submission06-Mar-2020
Date of Decision15-Mar-2020
Date of Acceptance29-Apr-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Abhishek Juneja
Department of Neurology, Dr. RML Hospital, A-15, Ramesh Nagar, New Delhi - 110 015, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333469

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How to cite this article:
Juneja A, Anand KS, Bhowmik S, Mahajan R, Dubey M. Anterior Cavernous and Internal Carotid Artery Thrombosis - A Rare Complication of Rhino-orbito-cerebral Mucormycosis. Neurol India 2021;69:1876-7

How to cite this URL:
Juneja A, Anand KS, Bhowmik S, Mahajan R, Dubey M. Anterior Cavernous and Internal Carotid Artery Thrombosis - A Rare Complication of Rhino-orbito-cerebral Mucormycosis. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1876-7. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1876/333469




Dear Sir,

We report a case of a 52-year-old female patient presented with headache and double vision for 15 days, complete vision loss in the right eye for five days, and left-sided body weakness for the last two days. She had a past medical history of long-standing uncontrolled diabetes mellitus. On physical examination, she had right eye ptosis with complete ophthalmoplegia. She had the only perception of light in the right eye with normal vision in the left eye. Her right pupil was dilated with absent pupillary reaction to light. Extraocular movements in the left eye were normal. Bilateral fundi were normal. She had upper motor neuron type left-sided facial palsy. On motor examination, she had moderate left-sided hemiparesis with an ipsilateral extensor plantar response. Her glycosylated hemoglobin (HbA1c) levels were 11.8%. She did not have diabetic ketoacidosis. Blood culture did not show any growth. Cerebrospinal fluid (CSF) examination showed mild protein elevation without any cellular response. Her CSF gram stain and culture results were negative. She underwent magnetic resonance imaging (MRI) of the brain showing an ill-defined T2 hypointense soft tissue in the region of right ethmoidal sinuses, and orbital apex extending to the superior part of the right cavernous sinus with heterogeneous post-contrast enhancement [Figure 1]a. It also revealed multiple right-hemispheric ischemic lesions [Figure 1]b and the absence of flow void with significant stenosis of the intracavernous segment of the right ICA in native T1 images [Figure 1]c. After a provisional diagnosis of rhino-orbital mucormycosis, she was started on liposomal amphotericin B (LAMB) injections. The diagnosis of mucormycosis was confirmed later on KOH wet mount staining of sinonasal specimens [Figure 2]. Despite the timely diagnosis and aggressive management, the patient succumbed to her illness after 5 days of admission.
Figure 1: (a) MRI brain coronal section showing heterogenous hypointensity involving right orbit and ethmoidal sinuses, (b) MRI brain axial section showing restricted diffusion in the right frontoparietal region suggestive of acute infarcts, (c) MRI brain showing the absence of flow void with significant stenosis of the intracavernous segment of the right internal carotid artery

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Figure 2: KOH wet mount and lactophenol cotton blue stain showing broad aseptate hyphae

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Rhino-orbito-cerebral mucormycosis (ROCM) is a rare aggressive fungal infection affecting paranasal sinuses, orbit, and the brain. It is acquired by various routes including inhalation, ingestion, or direct fungal contact to an open wound.[1] It usually affects patients with an immunocompromised state like diabetes mellitus, organ transplant recipients, and patients on chronic high dose steroids.[2] It rarely affects immunocompetent patients.

The internal carotid artery and cavernous sinus thrombosis are known as serious complications of this disease.[3] In general, the poor prognosis indicators in ROCM include delayed treatment, intracranial extension, and orbital involvement.[4] Moreover, a vascular extension of the disease like in our case would blunt the therapeutic response. Early diagnosis and treatment are critical in increasing the chance of survival.

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Conflicts of interest

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  References Top

1.
Singh V, Sharma B, Sen R, Agrawal S, Bhagol A, Bali R. Rhinocerebral mucormycosis: A diagnostic challenge and therapeutic dilemma in immunocompetent host. J Oral Maxillofac Surg 2012;70:1369-75.  Back to cited text no. 1
    
2.
Mohindra S, Mohindra S, Gupta R, Bakshi J, Gupta SK. Rhinocerebral mucormycosis: the disease spectrum in 27 patients. Mycoses 2007;50:290-6.  Back to cited text no. 2
    
3.
Talmi YP, Goldschmied-Reouven A, Bakon M, Barshack I, Wolf M, Horowitz Z, et al. Rhino-orbital and rhino-orbito-cerebral mucormycosis. Otolaryngol Head Neck Surg 2002;127:22-31.  Back to cited text no. 3
    
4.
Ketenci İ, Ünlü Y, Kaya H, Somdaş MA, Kontaş O, Öztürk M, et al. Rhinocerebral mucormycosis: experience in 14 patients. J Laryngol Otol2011;125:e3.  Back to cited text no. 4
    


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