PMC10061085_01
(A) Computed tomography scan of the chest in the case showing bilateral ground-glass opacities with a predominantly peripheral and multilobar location. (B,C) Orbital computed tomography scans of paranasal sinuses demonstrating opacification and air-fluid level in the left sphenoid sinus and some anterior ethmoid sinus air cells in right septal deviation to the right mucosal thickening in the left maxillary sinus.
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Bilateral pleural thickenings were also not reported (Figure 1A). According to the mucosal thickening and accumulation of secretions in paranasal sinuses (Figures 1B,C), the patient underwent endoscopic sinus and nasal surgery on day 7.
(A) Direct KOH microscopy of tissue samples.  Broad aseptate hyphae with wide-angle branches, and narrow septate hyaline hyphae with acute branching, are seen (x400). (B) Histopathological examination of tissue sections revealing a vascular structure involved, and containing both broad and thin fungal hyphae (x1,000).
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Samples from sinusitis and tissue necrosis were taken and subjected to direct microscopy using KOH preparation and also to H&E histopathological examination, and broad aseptate and narrower septate hyaline hyphae were seen in both of them (Figures 2A,B), suggestive of proven invasive mucormycosis and hyalohyphomycosis.
Surface and reverse of the isolated Rhizopus oryzae colony on Sabouraud dextrose agar after 4 days of incubation at 25 C (A,B), and its microscopic morphology by x100 and x400 magnifications, respectively (C,D).
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One of the colonies quickly covered the agar surface with dense growth, was cotton candy-like, white at first and then gray or yellowish-brown (Figure 3A), and its reverse was white to pale shades of gray or brown (Figure 3B). In the microscopic study of the slide culture prepared from the pure isolated colonies, broad hyphae with no or very few septa, numerous stolons running among the mycelia, and connecting groups of long sporangiophores were seen (Figures 3C,D).
Surface and reverse of the isolated Lomentospora prolificans colony on Sabouraud dextrose agar after 4 days (A,B), and after 20 days (C) incubation at 25 C when the mature colonies became dark gray to black and developed white mycelial tufts, and its microscopic morphology (D).
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The other isolated colonies were cottony or moist and light gray to black (Figure 4A), and the reverse was gray to black (Figure 4B). The mature colony became dark gray to black and developed white mycelial tufts over time (Figure 4C). In slide culture preparation, septate hyphae, conidiogenous cells (annelids) having a swollen base and elongated neck, and small clusters of olive to brown, one-celled, smooth, and ovoid with a slightly narrowed, truncated base conidia at the apex were observed (Figure 4D).