Septic cavernous sinus thrombosis in a patient with COVID-19.

The cavernous sinus is one of the dural venous sinuses which plays an important role in venous outflow from the brain and eye sockets and in the regulation of intracranial circulation. We report a case of septic cavernous sinus thrombosis in a female patient with COVID-19. The disease often results in alterations of blood rheology, thrombosis in different organs, and septic complications. This article aims to raise awareness of healthcare professionals about the characteristics of COVID-19 that might cause septic cavernous sinus thrombosis in patients with severe comorbidities. Laboratory testing revealed severe comorbidities, including diabetes mellitus and liver cirrhosis caused by hepatitis C. They manifested with an impaired protein production in the liver and coagulation disorders. Systemic effects of SARS-CoV-2 on the vascular endothelium aggravated preexisting coagulation disorders and led to hemorrhage into retrobulbar tissue and clinical signs of septic cavernous sinus thrombosis, including swelling of the eyelids, bilateral exophthalmos, and ophthalmoplegia, followed by necrosis of the facial skin.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Radiological findings of mucormycosis rhinosinusitis among Indian COVID-19 patients during the pandemic second wave

Background: Sinonasal mucormycosis is a quickly progressing and lethal fungal disease which showed an increased incidence in COVID-19 patients in the Indian population during the second wave of the pandemic. The objective of this study was to study the various sinus areas affected and the imaging findings of the disease. Method(s): The imaging records of patients with sinonasal mucormycosis during the second wave of the COVID-19 pandemic were reviewed and analysed for whom computed tomography (CT) and/or magnetic resonance imaging (MRI) images had been performed. Result(s): Of the 65 patients, 6.1% had single sinus involvement, and 93.9% had multiple sinus involvement, and out of latter, 91.8% had bilateral sinuses affected by the disease process. A total of 49.2% patients with sinus involvement had erosions of the sinus walls. A total of 35.4% patients had only sinonasal mucormycosis, 38.5% patients had rhino-orbital mucormycosis, 4.6% patients had rhino-cerebral mucormycosis and 16.9% patients had rhino-orbitocerebral mucormycosis. The pterygopalatine fossa was affected in 26.2% patients. A total of 9.2% patients had cavernous sinus thrombosis. A total of 12% of the cases had infarction in the cerebral hemispheres. Conclusion(s): In a setting of sinonasal mucormycosis, especially in the immuno-compromised and with those infected with COVID-19, cross-sectional imaging can assess the presence and extent of the disease and helps plan its medical and surgical management.Copyright © 2023, The Author(s).

Clinical and Neuroimaging Characteristics of Ischemic Stroke in Rhino-Orbito-Cerebral Mucormycosis Associated with COVID-19.

PURPOSE: The aim of this study was to compare clinical, neuroimaging, and laboratory features of rhino-orbito-cerebral mucormycosis (ROCM) in COVID-19 patients with and without ischemic stroke complications. METHODS: This observational study was conducted between August and December 2021 and 48 patients who had confirmed ROCM due to COVID-19, according to neuroimaging and histopathology/mycology evidence were included. Brain, orbit and paranasal sinus imaging was performed in all included patients. Data pertaining to clinical, neuroimaging, and laboratory characteristics and risk factors were collected and compared between patients with and without ischemic stroke complications. RESULTS: Of the patients 17 were diagnosed with ischemic stroke. Watershed infarction was the most common pattern (N = 13, 76.4%). Prevalence of conventional risk factors of stroke showed no significant differences between groups (patients with stroke vs. without stroke). Cavernous sinus (p = 0.001, odds ratio, OR = 12.8, 95% confidence interval, CI: 2.3-72) and ICA (p < 0.001, OR = 16.31, 95%CI: 2.91-91.14) involvement was more common in patients with stroke. Internal carotid artery (ICA) size (on the affected side) in patients with ischemic stroke was significantly smaller than in patients without stroke (median = 2.4 mm, interquartile range, IQR: 1.3-4 vs. 3.8 mm, IQR: 3.2-4.3, p = 0.004). Superior ophthalmic vein (SOV) size (on the affected side) in patients with stroke was significantly larger than patients without stroke (2.2 mm, IQR: 1.5-2.5 vs. 1.45 mm IQR: 1.1-1.8, p = 0.019). Involvement of the ethmoid and frontal sinuses were higher in patients with stroke (p = 0.007, OR = 1.85, 95% CI: 1.37-2.49 and p = 0.011, OR = 5, 95% CI: 1.4-18.2, respectively). Patients with stroke had higher D­dimer levels, WBC counts, neutrophil/lymphocyte ratios, and BUN/Cr ratio (all p < 0.05). CONCLUSION: Stroke-related ROCM was not associated with conventional ischemic stroke risk factors. Neuroimaging investigations including qualitative and quantitative parameters of cavernous sinus, ICA and SOV are useful to better understand the mechanism of stroke-related ROCM in COVID-19 patients.

Septic cavernous sinus thrombosis in a patient with COVID-19.

The cavernous sinus is one of the dural venous sinuses which plays an important role in venous outflow from the brain and eye sockets and in the regulation of intracranial circulation. We report a case of septic cavernous sinus thrombosis in a female patient with COVID-19. The disease often results in alterations of blood rheology, thrombosis in different organs, and septic complications. This article aims to raise awareness of healthcare professionals about the characteristics of COVID-19 that might cause septic cavernous sinus thrombosis in patients with severe comorbidities. Laboratory testing revealed severe comorbidities, including diabetes mellitus and liver cirrhosis caused by hepatitis C. They manifested with an impaired protein production in the liver and coagulation disorders. Systemic effects of SARS-CoV-2 on the vascular endothelium aggravated preexisting coagulation disorders and led to hemorrhage into retrobulbar tissue and clinical signs of septic cavernous sinus thrombosis, including swelling of the eyelids, bilateral exophthalmos, and ophthalmoplegia, followed by necrosis of the facial skin.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Superior ophthalmic vein and cavernous sinus thrombosis associated with COVID-19: a case report / Trombose de veia oftálmica superior e seio cavernoso associada à COVID-19: relato de caso

ABSTRACT Cavernous sinus and superior ophthalmic vein thrombosis is a rare clinical condition, and little described in the literature. The clinical presentation is nonspecific and highly variable, and symptoms may include red eye, ophthalmoplegia, coma, and death. The main etiology results from infection of the paranasal sinuses. The final diagnosis must be made through imaging tests such as magnetic resonance imaging. We describe a case of cavernous sinus and superior ophthalmic vein thrombosis after COVID-19 infection in a 64-year-old patient with persistent ocular hyperemia and pain on eye movement. Ophthalmological examination showed preserved visual acuity, conjunctival hyperemia, dilation of episcleral vessels and retinal vascular tortuosity in the right eye. Magnetic resonance imaging confirmed the diagnosis. The association with the COVID-19 was raised, excluding other infectious causes. Enoxaparin and Warfarin were started with significant improvement in the ocular clinical presentation and maintenance of initial visual acuity after 12 months of follow-up.

RESUMO A trombose de seio cavernoso e veia oftálmica superior é uma condição clínica rara e pouco descrita na literatura. A apresentação clínica é inespecífica e altamente variável. Os sintomas podem incluir olho vermelho, oftalmoplegia, coma e morte. A etiologia principal resulta da infecção dos seios paranasais. O diagnóstico final deve ser efetuado por meio de exames de imagem, como ressonância magnética. Descrevemos um caso de trombose de seio cavernoso e veia oftálmica superior após COVID-19 em paciente de 64 anos e com quadro de hiperemia ocular persistente e dor à movimentação ocular. Ao exame oftalmológico, observou-se acuidade visual preservada, hiperemia conjuntival, dilatação de vasos episclerais e tortuosidade vascular retiniana em olho direito. A ressonância confirmou o diagnóstico. A associação com a COVID-19 foi levantada, excluindo-se demais causas infecciosas. Prescrevemos enoxaparina e varfarina, com melhora do quadro clínico ocular e manutenção da acuidade visual inicial após 12 meses de acompanhamento.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Acute Fulminant Mucormycosis Triggered by Covid 19 Infection in a Young Patient.

Covid 19 infection can result in various opportunistic infections. Altered immune response, associated comorbid conditions like diabetes, prolonged steroid and broad spectrum antibiotics usage with ICU interventions lead to increased chance of such superadded infections in covid 19 patients. Here we report a case of 31 year old male with covid 19 infection who had new onset Diabetes Mellitus, developed severe acute fulminant Mucormycosis during the treatment for covid 19 infection. He presented with severe headache, nasal obstruction and discharge, bilateral ophthalmoplegia and blindness with Cavernous Sinus Thrombosis. Patient underwent aggressive surgical debridement with frontal craniectomy, maxillectomy and right orbital evisceration and left endoscopic orbital decompression and judicious efforts to revert back the immunocompromised status with high dose of Liposomal amphotericin. Post operatively patient developed right temporal lobe abscess which was drained through Endonasal Endoscopic Trans Cavernous drainage of Temporal Lobe Abscess. Patient is in 2 months follow up, with bilateral blindness and tolerating oral feeds with improved left eye ophthalmoplegia. It is imperative to note that the rising trend of mucormycosis is there in Covid 19 infections and it should be dealt with high index of suspicion in high risk patients and early aggressive treatment can save the patient as the survival rate is not high in such infections.

RADIOLOGY OF RHINOORBITOCEREBRAL MYCORMYCOSIS IN PATIENTS AFTER COVID-19.

Purpose. The analysis of CT and MR patterns of rhinoorbitocerebral mucormycosis (ROCM) among patients with type 2 diabetes (T2D) after COVID-19. Materials and methods. The study included 11 patients with confirmed COVID-19 and invasive ROCM in the long-term period. CT examinations were performed on Revolution EVO CT scanner (GE, Russia) and MRI on Aera MR scanner 1.5 T (Siemens, Germany). Results. We report several CT and MR patterns for a series of patients: involvement of paranasal sinuses, orbits, optic nerves, large arteries;intracranial spread;involvement bones of cranial base. The features of differential diagnosis and recommendations for standard protocols are presented. Conclusion. CT of paranasal sinuses is the method of choice for suspected fungal infections. MRI is recommended if there is a suspicion of orbital, vascular, and intracranial complications or cavernous sinus extension. The combination of both methods makes it possible to showed soft tissue invasion and bony destruction to choose optimal medical tactics ROCM.Copyright © 2022 Russian Electronic Journal of Radiology. All rights reserved.

Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners.

Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.

Cavernous Sinus Thrombosis Linked to COVID-19 Infection: a Case Report.

The severity of SARS-CoV-2 virus infection is mainly related to its respiratory complications. However, it can also lead to a large variety of thromboembolic events. Symptoms may include headache, fever, and neurological disorders. Since 2020, the clinical presentation of COVID-19 infection has become increasingly varied, leading in some cases to complex symptom associations, including numerous neurological symptoms. SARS-CoV-2 may lead to neurotropism which could reach the central nervous system and all cranial nerves. Cavernous sinus thrombosis is a rare condition and may occur as a complication of ear, nose, and throat (ENT) or facial infections. A 73-year-old man without personal or family history of thrombosis was referred to the emergency room for a sudden appearance of diplopia and ptosis, 3 days after testing positive for COVID-19 infection. An initial head CT-scan found no signs of stroke. He underwent a cerebral MRI 7 days later, which revealed a thrombosis of his right cavernous sinus. A brain CT scan 7 days later showed regression of the thrombosis with complete recanalization of the cavernous sinus. This was accompanied by a complete regression of diplopia and fever. He was discharged from the hospital 10 days after hospital admission. In this case report, we describe a rare event of cavernous thrombophlebitis following a COVID-19 infection.

Bilateral Cavernous Sinus Thrombosis in Presumed COVID-19 Infection.

Cavernous sinus thrombosis (CST) is a rare life-threatening condition where a blood clot develops within the cavernous sinus secondary to various etiologies, ranging from infection to aseptic causes (e.g., trauma or surgery). The dural sinuses and the cerebral veins have no valves, which allow retrograde blood flow according to pressure gradients. As a result, cavernous sinuses are vulnerable to septic thrombosis from infection at various sites including sphenoid and ethmoid sinuses. Less commonly, infections of the face, ears, nose, tonsils, soft palate, and teeth may lead to CST if treatment is delayed. Clinical findings of CST extending to the opposite cavernous sinus typically requires 24-48 hours after the initial presentation of orbital signs. However, we present a patient with facial and orbital cellulitis that was immediately treated with high-dose IV antibiotics within one hour of presentation and IV heparin six hours after admission and CST diagnosis. However, the patient developed a rapid progression of bilateral CST within six hours, unresponsive to treatment. Although facial cellulitis may lead to septic CST if untreated, the rapid progression of bilateral CST in the setting of acute hypoxic respiratory failure, renal failure, and coagulation abnormalities suggests a possible underlying infection and complications similar to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Stroke in patients with COVID associated Mucormycosis: A Report of Two Cases

Mucormycosis is a rare and invasive fungal disease with potentially fatal outcome. It most commonly affects patients with compromised immunity, especiallly those with poorly controlled diabetes. The incidence of mucormycosis has increased after the COVID-19 pandemic and both COVID-19 and mucormycosis are associated with an increased incidence of stroke. We present a report of two cases of COVID associated mucormycosis who had stroke. A 50-year-old patient with uncontrolled diabetes developed swelling of left eye and face ultimately leading to complete ophthalmoplegia of left eye. Imaging studies of brain revealed infarcts. MRI/MRA brain showed left internal carotid artery thrombosis, cavernous sinus thrombosis and a brain abscess in left temporal lobe. A second patient was a 65-year-old diabetic and hypertensive male who had COVID and then developed right MCA territory infarct and right sided cavernous sinus thrombosis. Diagnostic nasal endoscopy and biopsy was suggestive of mucormycosis in both the cases. Both these cases were managed with combination of tight glycemic control, antifungal therapy, and surgery. Clinicians should be aware of the association of stroke with COVID and COVID associated mucormycosis (CAM). Copyright © 2022 International Medical Sciences Academy. All rights reserved.

A case report on recurrent alternating Tolosa-Hunt syndrome due to bacterial sphenoid sinusitis: rediscussing the diagnostic terminology and classification.

BACKGROUND: Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia caused by idiopathic granulomatous inflammation involving the cavernous sinus region. Patients respond well to steroid therapy. THS is included in the differential diagnosis of cavernous sinus syndrome, so it is important to fully exclude other lesions in this area before treatment, otherwise steroid treatment may lead to fatal outcomes. Here we describe a patient who initially presented with symptoms that simulated THS symptoms and developed recurrent alternating painful ophthalmoplegia during follow-up, and the patient was finally diagnosed with cavernous sinusitis caused by bacterial sphenoid sinusitis. CASE PRESENTATION: A 34-year-old woman presented with left painful ophthalmoplegia. Magnetic resonance imaging (MRI) revealed abnormal signals in the left cavernous sinus area, and these abnormal signals were suspected to be THS. After steroid treatment, the patient obtained pain relief and had complete recovery of her ophthalmoplegia. However, right painful ophthalmoplegia appeared during the follow-up period. MRI showed obvious inflammatory signals in the right cavernous sinus and right sphenoid sinus. Then nasal sinus puncture and aspiration culture were performed, and the results showed a coagulase-negative staphylococcus infection. After antibiotic treatment with vancomycin, the painful ophthalmoplegia completely resolved, and the neurological examination and MRI returned to normal. CONCLUSION: Some other causes of painful ophthalmoplegia also fulfill the diagnostic criteria for THS in the International Classification of Headache Disorders third edition (ICHD-3) and respond well to steroid therapy. Early diagnosis of THS may be harmful to patients, and clinicians should exercise great caution when dealing with similar cases without a biopsy. Using "cavernous sinus syndrome" instead of "Tolosa-Hunt syndrome" as a diagnostic category may provide a better clinical thinking for etiological diagnosis.

Multi-System and Cavernous Sinus Inflammatory Syndrome Presenting with Evolving Multiple Cranial Neuropathies Following Zoledronate Infusion

Case report - Introduction: Bisphosphonates are known to rarely cause multi-system inflammation, including multiple cranial neuropathies. This is possibly via provoking transient cytokine storm. The literature reports bisphosphonate-associated orbital inflammatory syndrome, and one case of retrobulbar optic neuritis following zoledronate. Bisphosphonate manufacturers report conjunctivitis, blurred vision, scleritis, orbital inflammation, uveitis and episcleritis as ocular side effects. Separately, neurological sequalae, including cranial neuropathies, are reported following COVID-19 infection and vaccination. Here, we report the first case of cavernous sinus inflammation temporally related to both zoledronate infusion, and more remotely, to Pfizer- BioNTech COVID-19 vaccination. Case report - Case description: A 76-year-old white man developed fever, bony leg pain - which rendered him unable to walk - and frontal headache, within 8 hours of his first zoledronate infusion for osteoporosis. A few weeks earlier he received his first Pfizer-BioNTech COVID-19 vaccine. His General Practitioner commenced a short course of lowdose oral prednisolone for the episode. One week later, off prednisolone, the headache localised around the left eye. He developed horizontal diplopia associated with abduction deficit. He was diagnosed with left VIth nerve palsy. He was started on high-dose steroids and clopidogrel (with PPI) with neuroimaging to exclude stroke or venous sinus thrombosis. Two weeks later, the diplopia worsened over 4 days, with new left adduction deficit (-2 limitation), left ptosis 1-2mm and anisocoria 0.5-1mm R>L suggestive of partial third nerve palsy and early Horner's syndrome. Ocular and neurological examinations were otherwise normal. He wore varifocals and had migraines, osteoporosis, and asthma, for which he used inhalers. He worked in visual arts and was an ex-smoker (>50 years) with moderate alcohol intake. Blood results revealed CRP 38mg/L, but otherwise normal inflammation/ vasculitis/infection screen;anti-thyroglobulin antibodies were >4000 U/ml;GQ1P, Creatinine Kinase, anti-ganglioside, and Anti- AChR/MuSK antibodies were normal. CT head and Optical Coherence Tomography were unremarkable. An enhanced MRI of the brain and orbits revealed abnormal thickening and T2 hyper-intensity of the left oculomotor nerve, most notably involving the left canalicular portion. The left cavernous sinus also appeared asymmetrically bulky with a rind of abnormal enhancing soft tissue in the left cavernous sinus. Subtle STIR hyper-intensity was also observed in the ipsilateral CN IIIinnervated extra-ocular muscles. After a 6-week course of tapering prednisolone, the vertical diplopia and leg swelling persisted;the horizontal diplopia and headaches had resolved. By 3months, there was resolution with mild residual visual changes. Case report - Discussion: We report a constellation of symptoms relating to multi-system inflammatory syndrome involving the cavernous sinus. There is a lack of epidemiological data on the incidence of this rare presentation in the population. This case has close temporal association to bisphosphonate infusion (<12h) and weaker association to coronavirus vaccination (<3wk). It is difficult to determine whether this is a rare presentation of a known drug reaction, a more delayed presentation of a vaccine reaction or whether these events were coincidental. A further possibility in this case is a combined predisposition resulting from both vaccination and bisphosphonate infusion. This case highlights a wider issue relating to the challenging possibility of ascertainment bias and increased 'Yellow Card' reporting of rare presentations during this historic global coronavirus pandemic, which may or may not have any true causal association to vaccination. There is difficulty in disentangling a true vaccine reaction from an unrelated presentation of a rare condition with an unknown baseline incidence rate. This is especially topical given that the majority of the population are receiving the coronavirus ccination at this time. We also question what a plausible cut-off point would be to propose a temporal relationship for an adverse reaction;in the literature, adverse reactions have been postulated to develop beyond 1 month after the provoking agent. Case report - Key learning points: . This case highlights the need for urgent assessment, investigations including neurological imaging and consultant input in patients with evolving cranial neuropathy. The priority is to rule out thrombotic, compressive, inflammatory and infectious pathology in the cavernous sinus, venous sinus, orbit and orbital apex. . Pathology of the cavernous sinus presents with variable involvement of CN III, IV, V and VI and Horner's syndrome. A differential for this case would be superior orbital fissure syndrome, which also presents with multiple oculomotor cranial neuropathies;it involves these cranial nerves and the ophthalmic branch of CN V. Orbital apex syndrome is SOF with a loss of vision due to additional CNII involvement. . The neuro-radiology differential included inflammatory, infiltrative, granulomatous and neoplastic aetiologies and that there was sufficient existing evidence to exclude brainstem pathology. . Through communication between specialties, the temporal relationship was established, and clinical examination and extensive investigation further honed the differential to either inflammatory or vascular. Since it was temporally related to the zolendronate infusion, it seemed plausible it was related. We demonstrate the need for multi-disciplinary collaboration for these patients between rheumatology, ophthalmology and neuro-radiology.

Utility of F-18 FDG PET/CT in a Rare Case of Tolosa-Hunt Syndrome secondary to COVID 19 nasopharyngeal swab trauma, when MRI is inconclusive

Aim/Introduction: Tolosa-Hunt Syndrome (THS) is a rare disease with incidence rate of about 1/106 per year worldwide. Etiology include idiopathic granulomatous, nonspecific unilateral inflammation of the superior orbital fissure- cavernous sinus, causing severe headaches, eye pain, and ophthalmoplegia- paresis of the cavernous sinus nerves, sometimes Horner syndrome. THS is a diagnosis of exclusion that requires careful ruling out of alternative diagnoses. Material(s) and Method(s): We report an interesting case of 45 years old lady, who presented with complains of left sided headache, left eye retro-orbital pain with diplopia (double vision), ptosis and gradual difficulty in eye movements since last 2 months. She had history of nasopharyngeal mucosal swab collection for COVID 19 RT-PCR test after which she started complaints of pain along nasopharynx and later along ipsilateral eye orbit. MRI of brain and bilateral orbit suggested mild relative prominence of peri-optic CSF space along left side, without any abnormality along cavernous sinus or rest of the brain parenchyma. FDG PET/CT (PET/ CT) scan was performed to rule out other cause of THS showed impaired tracer uptake along left eye rectus muscles, suggesting paresis of CN III, IV and VI without any abnormal metabolically active lesion in brain parenchyma or rest of the body. Result(s): Based on clinical, radiological and PET/CT findings presumptive diagnosis of resolving left sided THS secondary to trauma induced inflammation was made. The patient shows clinical improvement after treatment with high dose steroid on follow up. Conclusion(s): PET/CT is helpful in detection of inflammatory tissue is a recognized fact. When MRI is unable to shows any tissue abnormality in cavernous sinus or superior orbital fissure;PET CT can play a role in its ability to demonstrate the paresis of cranial nerves supplying ipsilateral eye extrinsic muscles. Thus reaching the diagnosis of post traumatic inflammatory THS by exclusion. This case of THS with unique PET/ CT findings imply the useful indication of PET/CT in detecting and monitoring of treatment response in THS when MRI is inconclusive.

Pathomorphological features of the necrotic orbital wall lesions and orbital soft-tissue lesions in COVID-19-associated cavernous sinus thrombosis: a case report

This paper describes a case of COVID-19-associated cavernous sinus thrombosis complicated by panophthalmitis, orbital cellulitis and necrotic purulent complications in other maxillofacial structures. In addition, we present the results of the pathomorphological study of orbital wall and orbital soft-tissue material excised during surgery. The pathomorphological findings in the orbital tissues included signs of a chronic inflammatory process with mostly lymphocyte infiltration, a proliferative component and development of mixed-type thrombi. © Oripov O. I., Bilalov E. N., Israilov R. I., Umarov R. Z., Bilalov B. E., Khudaibergenov G. U., 2022.

A clinicoepidemiological study of orbital mucormycosis in COVID-19 pandemic at a tertiary healthcare hospital, North-West Rajasthan, India

Background Mucormycosis is an opportunistic fungal infection with high morbidity and mortality. Purpose The aim of this study was to determine the risk factors, clinical presentation, management, and outcome of management of orbital mucormycosis during the coronavirus disease 2019 (COVID-19) pandemic. Patients and methods This is a prospective hospital-based observational study that was conducted on cases of rhino-orbital cerebral mucormycosis (ROCM) presented to a tertiary health-care center in North-West Rajasthan, India, during the second wave of COVID-19 over a period of 1 month (May 26, 2021 to June 25, 2021). The patients were followed up for 3 months. A total of 40 cases fulfilling the clinical, radiological, and pathological or microbiological criteria for the diagnosis of ROCM were included in the study. Results Out of a total of 126 mucormycosis patients, 40 had ocular manifestations ranging from lid edema, chemosis, and ptosis to severe manifestations such s ophthalmoplegia, optic neuritis, and cavernous sinus thrombosis. Rare presentations of corneal eschar and corneal ulcer were also reported. Among the 40 patients of orbital mucormycosis, 57.5% were in the age group of 51-65 years, 65% were males, 62.5% were COVID positive, 37.5% had a history of oxygen therapy during the COVID-19 illness, and 85% were not vaccinated against COVID-19. All patients with orbital involvement had rhinitis at presentation. Intravenous Amphotericin B was given to all patients. Functional endoscopic sinus surgery was done in 92.5% of the cases and orbital exenteration was done in 35% of the patients to prevent the spread of mucor and to reduce mortality. In 32.5% of the patients, retrobulbar Amphotericin B was given. The mean length of hospital stay was 24.62±11.70 days and 70% of the patients were discharged from the hospital on oral antifungal therapy. A total of 30% of the patients with cerebral involvement passed away. During the follow-up of 3 months, three (7.5%) more patients who discontinued treatment progressed to advanced disease and died, while 62.5% (25 out of 40) patients were alive with stable/regressed disease. The survival rate with retrobulbar Amphotericin B was 92.30% and with exenteration was 92.85%, which was statistically significant compared with the 5% survival rate in the cases in whom no such intervention was done. Conclusion Early diagnosis and treatment of ROCM reduced morbidity and mortality in mucormycosis patients. © 2022 Delta Journal of Ophthalmology ;Published by Wolters Kluwer - Medknow.

Co-infections due to Aspergillus and Mucorales: Case series from a superspecialty medical center in India

Objectives: To present details of a case series of fungal co-infection (aspergillosis and mucormycosis) including clinical course, laboratory diagnosis, treatment, and outcome. Method(s): Clinical histories of 7 cases of fungal co-infection (3 pulmonary, 4 rhino-orbito-cerebral or sino-nasal) were collected by chart review, and reports of samples sent to the mycology laboratory for direct microscopy and fungal culture were retrieved from laboratory records.Presence of septate and aseptate hyphae in direct microscopy of clinical samples and/or growth of Aspergillus spp and Mucorales in culture was considered as evidence of probable co-infection with mucormycosis and aspergillosis (as per EORTC guidelines). Result(s): Mechanical ventilation, cavitary lung disease, and renal failure with metabolic acidosis were unique risk factors observed for pulmonary co-infection, while use of systemic corticosteroids for treatment of SARS-CoV-2 infection was common in rhino-orbito-cerebral (ROC) or sino-nasal (SN) co-infection. Diabetes mellitus was a common risk factor for both groups of cases. Fever, cough, chest pain, and shortness of breath were the most common features in pulmonary fungal co-infection cases, while headache, facial swelling and pain, nasal stuffiness, decreased vision, and altered sensorium were the most common features in ROC/SN co-infection. Consolidation or collapse, bronciectasis, cavitatory changes in and nodules were the most frequent radiological features in pulmonary fungal co-infection cases, while mucosal thickening in multiple paranasal sinuses, and involvement of orbit and cavernous sinuses were the most frequent features in ROC or SN co-infection. Presence of aseptate and septate hyphae in direct microscopy was seen in tissue samples from all ROC/SN cases, which enabled early intervention. However direct microscopy was not indicative of co-infection in any of sputum samples from pul-monary cases, and diagnosis was only established by culture, leading to delayed initiation of treatment or no treatment. Lipo-somal amphotericin B (lAMB) ranging from 50-200 mg/day was used for treatment of fungal co-infection, with posaconazole 600-800 mg/day as step-down therapy or if lAMB was not tolerated. Out ofthree pulmonary fungalco-infection cases, onlyone received appropriateantifungal treatment butexpired nonethe-less. Out of the two untreated patients, one expired, and one was discharged against medical advice without resolution of symptoms. Surgical intervention was not done for any patient. In comparison, 3 out of 4 cases of ROC/SN co-infection were appropriately managed with immediate surgical debridement and survived. The remaining patient received appropriate anti-fungals but refused surgical intervention and expired. Conclusion(s): Fungal co-infection with aspergillosis and mucormycosis is a serious condition requiring early intervention. This is facilitated by high sensitivity of direct microscopy in tissue samples used for diagnosis in ROC/SN co-infection, but hindered by low sensitivity of direct microscopy in sputum/BAL samples used for diagnosis in pulmonary cases rather than lung biopsy. Robust clinical advisory services, early diagnosis, and combined surgical and pharmacological approaches are crucial to a favorable outcome.

A case of aseptic bilateral cavernous sinus thrombosis following a recent inactivated SARS-CoV-2 vaccination.

This case report aims to describe the first report of bilateral aseptic cavernous sinus thrombosis (CST) with a recent history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. A 50-year-old woman presented with bilateral proptosis, decreased vision, and ophthalmoplegia 16 days following CoronaVac® vaccine. The visual acuity of the left eye was 20/150, while the right eye was no light perception with a hyperemic optic nerve head. She had a history of hyperthyroidism and currently on warfarin consumption. Laboratory results depicted elevated free T4, free T3, international normalized ratio, and low protein S and C. Magnetic resonance imaging showed bilateral CST, and high-dose methylprednisolone along with fondaparinux was given. The symptoms were significantly resolved, with the visual acuity of the left eye being improved to 20/20 but not the right eye. Bilateral CST has not been previously reported following inactivated SARS-CoV-2 vaccination. The underlying systemic conditions should be taken into consideration for the possibility of the inactivated SARS-CoV-2 vaccine-related event.

Asymptomatic post-traumatic bilateral ophthalmic vein and cavernous sinus thrombosis

Purpose: To highlight the considerations in clinical diagnosis and management of ophthalmic vein thrombosis through a challenging case of asymptomatic posttraumatic bilateral superior ophthalmic and cavernous sinus thrombosis. Method(s): A review of electronic medical records. Result(s): A 54-year-old female with no significant past medical history presented to a tertiary trauma and referral hospital two hours after falling from a ladder and sustaining significant head and torso polytrauma. She had a second dose of BNT162b2 COVID-19 mRNA vaccination two weeks earlier. Contrast computed tomography imaging confirmed the presence of bilateral superior and inferior ophthalmic vein thrombi, and suspected cavernous sinus thrombi without carotid-cavernous fistula. The patient's presentation occurred in the absence of any neurological or ophthalmic signs or symptoms, and her visual acuity remained normal throughout follow-up. A serological inflammatory, infectious, and thrombotic screen was negative. Repeat computed tomography imaging demonstrated successful resolution of all thrombi following treatment with systemic anticoagulation. Conclusion(s): This unusual case of bilateral ophthalmic vein thrombi highlights a challenging diagnosis that should not be overlooked despite a normal neurological and ophthalmic examination. Although the cause of SOVT was likely post-traumatic, contribution from recent nVoC-19 vaccination was investigated.