PMC3336238_01
(a) CT scan of patient with invasion of left paranasal sinuses and orbit. (b) Necrotic sinus tissue found on endoscopy.
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fig1
Because of persistent fever, and the sinus maxillary clinical signs, a CT scan of the head was performed; it showed a solid image inside the left maxillary sinus, proptosis of the left eyeball, and destruction of the structures adjacent to the nose (Figure 1(a)). Following these findings, a nasal endoscopy was performed promptly, and it showed an extensive necrosis of the left medial turbinate (Figure 1(b)).
Biopsy with silver stain showing large pauciseptate hyphae invading tissue.
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An incisional biopsy report showed necrosis and hemorrhage with nonseptate hyphae 90  degree branched (Figure 2), and Mucor sp. was identified on culture (Figure 3) since the first procedure intranasal amphotericin was instilled.
Sporangiophores with big sporangia, with no apophysis, rhizoids or stolones, compatible with Mucor sp.
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fig3
An incisional biopsy report showed necrosis and hemorrhage with nonseptate hyphae 90  degree branched (Figure 2), and Mucor sp. was identified on culture (Figure 3) since the first procedure intranasal amphotericin was instilled.
Aspect of patient with periorbital edema and ecchymosis of the surrounding skin.
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On arrival her vital signs were unstable, she was found to have facial asymmetry, periorbital edema, and bilateral proptosis (mainly right eye) with ecchymosis of the surrounding skin, her right pupil did not react to light stimuli (Figure 4).
(a) KOH exam showing nonseptate hyphae branched at 90 degrees. (b) Sporangiophores with sporangia and underdeveloped stolones, compatible with Rhizomucor sp.
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fig5
Postmortem, a nasal biopsy and swab were taken and found compatible with rhinocerebral invasive zygomycosis due to the observation of nonseptate hyphae branched at 90  degrees (Figure 5(a)). Two days later a zygomycete was grown and identified as Rhizomucor spp. (Figure 5(b)).