PMC8366463_01
(A) left facial droop and deviation of mouth to right side; (B) left sided absence of forehead wrinkling and left sided ptosis; (C) inability to open eye and absent eyeball movement on left side upon being asked to look up
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F1
Neurological examination revealed deviation of angle of mouth to the right side with absent wrinkling of forehead on left side, abnormal grimace with hypoesthesia in distribution of V1, V2 branches of left trigeminal nerve (Figure 1).
(A) Chest X-ray posteroanterior (PA) view: There are right upper and lower zone cavitary lesions showing radiopacity in dependant parts and air-crescent sign along the non-dependant parts. Multiple alveolar infiltrates and llinear strands are seen in left upper and middle zones; (B) Contrast-enhanced magnetic resonance imaging (CEMRI) of brain; T1 (axial scan at the level of base of skull) showing enhancenment of basisphenoid, clivus, and basiocciput. Contrast enhancement is extending to left sided retroantral fat and posterolateral wall of left maxillary sinus and contents of left infratemporal fossa. Left maxillary sinus shows mucosal thickening along the posteromedial wall, air fluid level and some hyperdensity along the medial wall. All these findings are suggestive of invasive fungal sinusitis; (C) CEMRI of brain (axial scan) at the level of cavernous sinus and orbits showing post contrast enhancement of left optic canal and optic nerve. A small filling defect is noted in left cavernous sinus as well as outward bulge of the lateral wall, which indicates thrombosis; (D) Consultation contrast-enhanced CT scan (CECT) of chest showing cavitary lesion in right middle lobe with air crescent sign along the non-dependant part and ball-like soft tissue along the dependant part of cavity. Adjacent lung parenchyma posterolaterally shows consolidaion and thickening of abutting right oblique fissure; (E) Haematoxylin and eosin (H&E) stain (20x10) fungal profiles can be seen invading vessel wall accompained by dense inflammatory cell infiltrate comprising neutrophils, lymphocyte, and few scattered eosinophils and plasma cells
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F2
His chest radiograph revealed fibrotic bands along with cavitary lesion with surrounding consolidation and air crescent sign present in both hemi thoraces (figure 2). It demonstrated acute left maxillary sinusitis with posterolateral wall erosion, prominent left optic nerve sheath, and skull base osteomyelitis with cavernous sinus thrombosis (Figure 2). In view of chest X-ray findings, after pulmonary consultation contrast-enhanced CT scan (CECT) of chest was performed to aid in decision regarding initiation of anti-tubercular therapy, which suggested tuberculosis reactivation (Figure 2). Histopathological examination (HPE) of excised tissue revealed broad aseptate hyphae with right angle branching invading both nerves and vessel wall, confirming diagnosis of invasive mucormycosis (Figure 2).