PMC6180875_01
(a, b) Axial and coronal plain CT scans in bone window showing mucosal thickening of the bilateral ethmoidal and maxillary sinuses (arrows). (c, d) Contrast-enhanced CT scan in the coronal and axial sections showing linear non-enhancing soft tissue (arrows) located superomedial to the optic nerve (broken arrow). The thickening of the medial rectus muscle and the surrounding fat stranding (arrowhead) is significant.
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Contrast-enhanced CT scan of the paranasal sinuses was perfmormed using 100 ml of Iohexol (Omnipaque 300 mgl ml-1; GE Healthcare, Shanghai, China) (Figure 1a,b), which showed moderate mucosal thickening of the paranasal sinuses, with no obvious hyperdense contents within the sinuses. A linear non-enhancing structure with surrounding fat oedema was seen in the left orbit, related superomedially to the optic nerve (Figure 1c,d).
(a) Axial plain CT scan in bone window after 5 days showing worsening sinusitis with development of air-fluid levels in bilateral maxillary sinuses (arrows). (b) Plain CT scan in the axial section at the level of the brain showing interval appearance of hypodense areas in bilateral inferior frontal lobes (arrows).
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Plain CT scan followed by contrast-enhanced MRI using Gadodiamide (Omniscan 0.5 mmol ml-1, GE Healthcare) was performed, which showed worsening of the sinusitis (Figure 2a) with development of new hypodense areas in the bilateral frontal lobes (Figure 2b) and the left caudate nucleus, which was suggestive of infarcts.
(a) Diffusion-weighted images with corresponding apparent diffusion coefficient maps shows multiple acute infarcts (arrows) in bilateral inferior frontal, left basal ganglia and right posterior watershed region. (b) MR angiography using non-contrast time-of-flight shows complete thrombosis of the right internal carotid artery (arrow). Broken arrow showing normal left internal carotid artery. (c) Axial contrast-enhanced T
1 weighted image showing faint enhancement of the infarcts (arrows). (d) Short tau inversion-recovery in coronal showing absent normal mucosal hyperintensity (arrow) covering the left inferior turbinate (in discrepant with the mucosal thickening on the CT scan). (e) Coronal contrast-enhanced T
1 (non-fat-saturated) weighted image shows non-enhancement of the left inferior turbinate mucosa (arrow)
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The contrast-enhanced MRI (Figure 3) revealed acute infarcts in the bilateral frontal lobes, right anterior and posterior watershed regions, left basal ganglia and left centrum semiovale (Figure 3a). ICA showed loss of normal signal void, with the MR angiography showing complete thrombosis of the right ICA (Figure 3b). Infarct in the left basal ganglia showed areas of blooming on gradient sequences. The infarcted areas also showed faint contrast enhancement (Figure 3c). The thickened mucosa lining the left middle and inferior turbinates appeared hypointense on the short tau inversion-recovery sequence and were non-enhancing on post-contrast administration (Figure 3d,e).
(a, b) Nasal biopsy with haematoxylin and eosin staining shows multiple broad, aseptate, irregular branching hyphae with obtuse angles, consistent with Mucor (arrows).
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A nasal biopsy was performed, which showed branching hyphae with obtuse angles invading the vessels, consistent with mucormycosis (Figure 4a,b).
(a, b) MRI repeated after 2 days in view of deterioration despite treatment shows increasing infarcts (arrows in a) and additional thrombosis of bilateral anterior cerebral arteries (arrowheads in b).
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