PMC6669373_01
(a) Head MRI without contrast (Coronal view) showing thickening of the right sided ethmoid and sphenoidal sinuses compatible with sinusitis. (b) Head MRI with contrast showing air fluid levels in the right ethmoid and sphenoidal sinuses.
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She subsequently underwent magnetic resonance imaging (MRI) study of the head and both orbits which revealed mucosal thickening with fluid levels in the ethmoid air cells and air-fluid levels in the sphenoid sinus (Fig. 1a and b).
Head MRI without contrast showing a heterogenous T1/T2 hypointense enhancing soft tissue in the right pterygopalatine fossa and right orbital apex, encasing the right optic nerve complex.
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T1/T2 hypointense enhancing soft tissue effacing fat planes in the right pterygopalatine fossa fat and right orbital apex with encasement of the right optic nerve sheath complex and extension into the anterior aspect of the right cavernous sinus (Fig. 2). The radiologist report describes concern for invasive sinus disease with mucormycosis or invasive aspergillosis as differential diagnoses.
(a) Hematoxylin and Eosin stains of histologic sections of the right lateral sphenoid recess showing invasive fungal sinusitis with associated foreign-body giant cell reaction and necrosis. Mag. 400x. (b) Grocott-Gomori methenamine silver stain of histologic sections of the right lateral sphenoid recess highlights numerous fungal non-septate branching hyphae, morphologically consistent with mucormycosis. Mag. 400x.
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Histopathology a week later from the right lateral sphenoid recess demonstrated again hyphae which are pauci-septated and irregular branching as well as chronic rhinosinusitis with eosinophils (>10/HPF) (Fig. 3a). GMS stain was positive again for fungal organisms, morphologically consistent with mucor (Fig. 3b).