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.

Disseminated Mucormycosis in a patient on long term immunosuppression: Severe fungal infections as multi-system disorders

Introduction: Mucormycosis is a rare, severe fungal infection with an incidence of 0.005 to 0.17 per million.1 but incidence has risen recently, particularly in the Asian subcontinent, due to use of immunosuppression for Covid19.2 Presentations can vary and are classified into: rhino-orbito-cerebral, pulmonary, cutaneous, disseminated, renal and gastrointestinal. Risk factors include diabetes, immunosuppression, iron overload, malnutrition, and prematurity.1,3 Although mucormycosis has an extremely high mortality rate and disseminated infection is usually fatal, treatment options exist if diagnosed early and surgical debridement may be curative. Objective(s): We present a case of mucormycois in a female patient in her 40s who was immunosuppressed with methotrexate for rheumatoid disease. This case is discussed to increase awareness of critical illness caused by opportunistic invasive fungal infections in immunosuppressed patients and promote timely identification and management. Method(s): We detail the clinical context and management of a patient with mucormycosis and discuss relevant literature. Result(s): A female patient in her 40s who had been experiencing upper respiratory tract symptoms for several weeks, including cough and brown sputum, was admitted with a presumptive diagnosis of methotrexate toxicity after a full blood count performed by the general practitioner demonstrated pancytopenia. Initially, National Early Warning System 2 score (NEWS2) was 2 but became intensely hypertensive during blood transfusion and then profoundly shocked with an escalating NEWS2. Broad-spectrum antibiotics and fluconazole were commenced for neutropenic sepsis and the patient was referred to critical care in multiple organ failure. Computerised tomography (CT) scan of the chest, abdomen and pelvis showed "left upper lobe consolidation, which with neutropenia might represent an angioinvasive aspergillosis". She had multiple areas of skin discolouration and desquamation. Haematology and Infectious Diseases opinions were sought, and a bone marrow biopsy was performed which showed severe toxic effects consistent with sepsis/life threatening infection. Progressive proptosis was noted, and CT scan of her head was requested. Sadly, she was never stable enough for CT transfer. Beta D Glucan and aspergillus antigen serology was negative. Broncho-alveolar lavage demonstrated Candida albicans and then, later, Rhizopus arrhizus was isolated and anti-fungal treatment changed to voriconazole and then amphotericin B. Upon reviewing the notes in light of the positive culture for Rhizopus, the patient had likely been exhibiting symptomatic Mucormycosis sinus infection for some time prior to this admission with disseminated infection. The patient's condition continued to deteriorate and she sadly died. Conclusion(s): * The Early Warning Score significantly underestimated how unwell the patient was upon arrival in ED, a systems-based assessment would have demonstrated that the patient had multiple system dysfunction and significant potential to deteriorate suddenly despite having stable observations * The methotrexate level has no clinical value in diagnosing or refuting a diagnosis of methotrexate toxicity * A full examination of the immunosuppressed patient including ENT is a necessity when searching for a source of infection * Invasive fungal infections can cause multi-system symptoms and atypical presentations * As a greater proportion of patients have received systemic immunosuppression for Covid-19, vigilance for more unusual pathogens, including Mucormycosis by clinicians is advised.

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.

Thyroid Eye Disease Following COVID-19 Infection in a Patient with a History of Graves' Disease

Introduction: Autoimmune and inflammatory thyroid diseases have been reported following SARS-CoV-2 infection or vaccination, but thyroid eye disease (TED) post-COVID-19 infection is less common. We describe a case of TED following SAR-CoV-2 infection in a patient with a history of Graves' disease. Case Description: A 59-year-old female with history of Graves' disease status post radioiodine ablation therapy in 2002. She developed post-ablative hypothyroidism which has been stable on levothyroxine 88 mcg daily. In January 2021, the patient's husband and daughter were diagnosed with COVID-19 infection. A few days later, the patient developed an upper respiratory tract infection associated with loss of sense of smell and taste consistent with COVID-19 infection. Three days later, she developed bilateral watery eyes which progressed to eye redness, eyelid fullness, retraction, and pain with eye movement over 1-month duration. Her eye examination was significant for severe periocular soft tissue swelling, lagophthalmos and bilateral exophthalmos. The laboratory workup was consistent with normal TSH 0.388 mIU/L (0.358-3.740 mIU/L) and positive TSI 1.01 (0.0-0.55). The patient was referred to an Ophthalmologist for evaluation of TED. He noted bilateral exophthalmos, no restrictive ocular dysmotility or compressive optic neuropathy (clinical activity score 4/7 points). CT scan of orbit showed findings compatible with thyroid orbitopathy. Based on clinical activity score of 4, treatment with Teprotumumab was recommended pending insurance approval. Discussion(s): Many cases of new-onset Graves' hyperthyroidism have been reported after COVID-19, with only a few associated with TED. Our patient has been in remission for 20 years before she developed COVID-19 infection with occurence of TED.This suggests that COVID-19 infection may have played a role. SARS-CoV-2 may act through several mechanisms, including breakdown of central and peripheral tolerance, molecular mimicry between viral and self-antigens, stimulation of inflammasome with release of type I interferon. In our patient, treatment with Teprotumumab was indicated due to Graves' orbitopathy clinical activity score greater than or equal to 3. In conclusion, it is very uncommon for TED to present after COVID-19 infection. Our case reinforces the speculative hypothesis that SARS-CoV-2 virus could have triggered an autoimmune response against eye antigens. There is a need for increased awareness about the link between COVID-19 and autoimmunity to help better define the management of patients.Copyright © 2023

Rhino-Orbital Mucormycosis in a COVID-19 Patient: A Dreadful Challenge

Coronavirus disease 2019 (COVID-19) is a pandemic disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). COVID-19 infections may be associated with a wide range of bacterial and fungal co-infections. Recent studies are reporting invasive fungal infection associated with severe COVID-19. Herein, we report a case of COVID-19 rhino-orbital mucormycosis infection caused by Rhizopus sps in a 32 year old diabetic patient who was successfully managed with early aggressive debridement of infected tissue endoscopically with extended ethmoidectomy by modified Denker's approach along with orbital decompression and antifungal therapy with Liposomal Amphotericin B and Posaconazole. Serial diagnostic nasal endoscopy showed no evidence of progression of the infection. The patient was discharged on 21st day of hospitalization still on oral Posaconazole for a total of 3 months. Copyright © 2022, Kathmandu University. All rights reserved.

Ocular adnexal lymphoma masquerading as orbital cellulitis in a child: A rare presentation!

Background: Extra-nodal natural killer/T-cell lymphoma (NKTCL) is a rare form of non-Hodgkin lymphoma (NHL). Few cases of Ocular adnexal T-cell lymphoma presenting as pre-septal cellulitis/orbital cellulitis has been reported in the literature. However, Extra Nodal NK/T cell non-Hodgkin lymphoma presenting as orbital cellulitis and also with multisystem involvement in the paediatric age group is a rare presentation and not reported earlier. Method(s): 13 years old male presented to us with weakness of left side with left facial palsy for 2.5 months and right eye severe proptosis and vision loss for 2 months. Initially, He was diagnosed with Orbital cellulitis and treated for the same from elsewhere. PET-CT showed FDG avid metabolic active largest soft tissue mass in left lung upper lobe encasing first rib, large active soft tissue mass in the periorbital area, right nasal cavity, right lobe of the thyroid, right kidney, pancreas head, scrotal area, multiple bony lesions. Further biopsy from rib mass revealed NK- T cell lymphoma. He was diagnosed with a rare case of NK/ T cell Non-Hodgkin Lymphoma with multisystem involvement. Initially, he responded to SMILE regimen of chemotherapy, but he developed white fluffy vitreous opacities in the left eye after 3 cycles, and before vitreous biopsy, he contracted COVID 19 infection. During COVID treatment he has received IV antibiotics and steroids. After recovery from covid illness, his vitreous opacities got disappeared suggestive of possible endophthalmitis rather than intraocular lymphoma. Later within two weeks, he succumbed to the disease. Result(s): Died with disease Conclusion(s): Our case highlights that ocular adnexal lymphoma can be a possible masquerade in cases of refractory lid swelling with erythema and induration and can present as orbital cellulitis with multisystem involvement. Copyright © 2022

Asymptomatic Thyroid Stimulatin Hormone/Growth Hormone Cosecreting Invasive Pituitary Macroadenoma: A Rare Case Report

Introduction: Thyrotropin (TSH)/growth hormone (GH) pituitary adenoma is rare and often characterized by specific signs and clinical presentations. The most common presentation of cosecreting TSH/GH pituitary adenomas is a combination of altered facial appearance (84%), goiter (91%) followed by hyperhidrosis (75%), hyperphagia (58%), trembling hands (50%), and vision impairment (50%). The patient with TSH and GH-producing pituitary adenoma had a lower surgical complete remission rate and a worse prognosis. Our case is unique in many ways in terms of the initial presentation, without having the specific signs and symptoms of TSH/GH-producing pituitary adenoma. Case Description: A 42-year-old diabetic man presented with decreased vision in the left eye for 1 month associated with the headache and nasal block during the COVID-19 pandemic. Therefore, a CECT of the brain was done which revealed a mass lesion in the pituitary fossa eroding the sphenoidal sinus, so a biopsy was done to rule out mucormycosis. The biopsy report is suggestive of a pituitary lesion with immunohistochemistry (IHC) the tumor cell is diffusely positive for GH with a high MIB labeling index of 15%. Subsequently, he had an MRI of the pituitary region showing a large heterogeneously mass of size (3.7 x 3.3 x 3.2) cm. So, he was referred to endocrinology for further evaluation. On examination BP 120/80;pulse rate 100/min. His blood sugar was under control with oral diabetic agents. General and systemic examination was unremarkable. No tremor, exophthalmos, acromegalic feature, or neck swelling. As mentioned earlier he was incidentally picked up as a pituitary mass by CECT during the evaluation of headache and vision loss. A biopsy along with IHC showed pluripotent pituitary adenoma with tumor cells diffusely positive for GH, focal positivity for TSH and occasional cells were prolactin positive. So, he was evaluated for the functionality of pituitary adenoma. His hormonal evaluation showed elevated IGF-1 395 ng/mL with nonsuppression of postglucose GH of 5.73 ng/dL associated with raised FT4 and FT3 with inappropriate elevated TSH which confirmed cosecretion of GH and TSH from the pituitary adenoma. Serum cortisol and prolactin were normal with low LH, FSH, and low testosterone. He underwent transsphenoidal excision of the tumor;postsurgery his thyroid profile was normal but his IGF1 and GH still remained high during subsequent follow-up. He was asked to follow up after 3 months to reimage and reevaluate his hormonal status and the next plan of treatment. Discussion(s): Most of the cases of GH/TSH-producing adenoma reported in the literature are symptomatic with some clinical features of acromegaly and thyrotoxicosis. Our case is asymptomatic GH/TSH producing invasive pituitary macroadenomas that picked up incidentally. Hence it may be necessary to do the IHC to find out the type of tumor cells harboring by pituitary adenoma as the cosecreting TSH/ GH tumor is usually aggressive and warrants prompt treatment. Copyright © 2022

Surgical Management of Rhino-Orbito-Cerebral Mucormycosis Post-COVID-19 Infection

Introduction: The pandemic of COVID-19 in association with mucormycosis would be a deadly fungal infection with high level of mortality and morbidity. Our aim is to evaluate the surgical outcome of patients with rhino-orbito-cerebral mucormycosis to suggest better management strategies. Method(s): A total of 62 cases of COVID-19-associated rhino-orbito-cerebral mucormycosis were admitted to the ear, nose, throat department in Mashhad, Iran, from August 1 to October 15, 2021. All data were analyzed using SPSS version 27.0. Descriptive analysis was used for demographic and clinical characteristics. Result(s): Main predisposing conditions were diabetes mellitus (90%) followed by hypertension (41%). Main symptoms were headache (75%), periorbital or retro-orbital pain (61%), visual loss (45%), and facial numbness (41%). Mucosal and ocular findings showed necrosis (67%), blindness (n=35), ptosis (n=31), proptosis (n=27), ophthalmoplegia (n=25), and chemosis (n=20). Neurologic loss of consciousness (19%) and palsies of cranial nerves (53%) were observed. Endoscopy findings showed necrosis (70%), discharge (61%), and crusting (54%). Imaging enhancement revealed mucosal thickening (69%), opacification of sinus (69%), bony destruction of sinus (35%), and orbital involvement (25%). Debridement surgery was necessary in nearly all patients (96%), dominated by ethmoid sinus (90%), maxillary sinus (87%), middle turbinate (80%), and sphenoid sinus (79%). Based on our follow-up, 25 patients died (42%). Those who survived will suffer from no light perception (35%), cranial nerve palsy (12%), and cerebral vascular accident (1.6%). Conclusion(s): Mucormycosis is an aggressive fungal infection. Diabetes mellitus, COVID-19 complication, inappropriate use of corticosteroids, and delayed vaccination had significantly increased its incidence. As there is an urgent need to address this public health concern, we present our data set from Iran.

NEW-ONSET THYROID EYE DISEASE AFTER COVID-19 VACCINATION: A CASE REPORT

Introduction The relationship between autoimmunity and SARS-CoV-2 vaccine has explained how thyroid dysfunction developed following vaccination but the onset of thyroid eye disease (TED) is scarcely described. We report a case of Graves' disease (GD) who developed TED after three weeks of BNT162B2 SARS-CoV-2 vaccine (Pfizer-BioNTech) injection. CASE A 54-year-old non-smoking male presented with newonset bilateral eyes redness, proptosis, and diplopia three weeks after receiving the second dose of mRNA BNT162B2 SARS-CoV-2 vaccine. He was diagnosed with GD without TED in 2003 and underwent radioactive iodine ablation in 2020. He subsequently developed hypothyroidism and was started on levothyroxine with stable thyroid function test throughout clinic visits. There were no recent stressful events including COVID-19 infection. On examination, he has bilateral exophthalmos, chemosis, conjunctival injection, swollen eyelids and caruncles, with intact vision. Blood tests revealed normal TSH, free T4, and T3, but elevated TSH-receptor antibodies of 3.60 IU/L (<1.75) and antithyroid peroxidase (TPO) antibodies of >600 IU/ml (0-34). MRI orbit showed bilateral extraocular muscle enlargement and proptosis. Intravenous methylprednisolone was given weekly for 12 weeks. There was significant improvement concerning congestive symptoms and diplopia after the third dose of methylprednisolone. Thyroid eye disease is the extrathyroidal manifestation of GD resulting from the autoimmune and inflammatory process. The temporal relationship of the onset of TED after mRNA SARS-CoV-2 vaccination in our case was suggestive, and there were no other inciting events identified. The postulated mechanisms include immune reactivation, molecular mimicry between the SARS-CoV-2 spike proteins and thyroid proteins, and the autoimmune/ inflammatory syndrome induced by adjuvants present in the mRNA vaccine. Conclusion Patients with autoimmune thyroiditis should be monitored closely after SARS-CoV-2 vaccine as they may develop TED and require treatment.

Neurological Spectrum Of Post Covid Rhino Orbital Cerebral Mucormycosis- An Observational Study in a Tertiary Care Centre in South India, Madurai

Objective: To provide an overview of the pattern of neuroaxis involvement and clinicoradiological correlation in post covid rhino orbital cerebral mucormycosis cases. Background: The COVID-19 has spread worldwide since December 2019. In India, the peak of COVID-19 Infections in APRIL 2021 was paralleled by an outbreak of rhino-orbital-cerebral mucormycosis (ROCM), a fulminant angioinvasive fungal infection involving various neural axis. Design/Methods: We systematically reviewed 100 patients diagnosed with post covid ROCM admitted to the hospital during APRIL 2021 to JUNE 2021. Data pertaining to clinicoradiological features were analysed using percentage of total cases. Results: Of 100 patients of post covid ROCM, clinical manifestations include headache[90%], facial pain [88%], ophthalmoplegia [87%], loss of vision [85%], proptosis [85%], dizziness [60%], cerebrovascular accidents [24%], seizures[20%], encephalitis[3%]. Radiological profile suggestive of Cranial nerve involvement [45%], Early cerebritis [40%], Cerebral abscess [25%], Cavernous sinus thrombosis[20%], ICA stenosis[16%], Cerebral infarct[9%], Leptomeningeal enhancement[6%]. Conclusions: Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of cranial nerves, extraocular muscles, meninges, cavernous sinus brain parenchyma and internal carotid artery. High index of suspicion is required to ensure timely diagnosis and appropriate treatment in high-risk populations to prevent High mortality.

Unilateral total ophthalmoplegia with proptosis and loss of vision in a patient of herpes zoster ophthalmicus: A rare case report

Herpes zoster Ophthalmicus accounts for a minority of all patients with zoster infections. It leads to varied clinical presentations, but total unilateral ophthalmoplegia has rarely been reported in the literature. We hereby present a 50-year-old male patient presenting with the above combination for aiding the clinical diagnosis by dermatologists and ophthalmologists. Early initiation of treatment leads to a near total recovery of ophthalmoplegia in the majority of treated patients.

Cranial nerve involvement in mucormycosis in post-COVID patients: a case series

Background: One of the largest outbreaks of rhinosinocerebral mucormycosis (RSCM) occurred in India close to the second wave of the SARS-CoV-2 infection. RSCM is a rare infection caused by several fungal species occurring in immunocompromised subjects. Mucor shows a high propensity to invade the central nervous system. There have been limited studies, mostly isolated case reports, on the neurological manifestations of RSCM. The outbreak of mucormycosis infection was thus the most opportune to study the neurological manifestations and cranial nerve involvement in mucormycosis in greater depths. Aim of the study: The purpose of the study was to investigate and review the involvement of cranial nerves in a series of cases of rhinosinocerebral mucormycosis associated with the novel coronavirus disease caused by SARS-CoV-2. Results: It was a retrospective cross-sectional study of seven patients who were undergoing treatment of RSCM with a recent history of coronavirus disease caused by SARS-CoV-2 infection within the last 3 months. Patients with cranial nerve involvement were identified by magnetic resonance imaging (MRI) at a single institution. Demographic details of the patients, clinical presentation, imaging, microbiological and pathological findings were recorded. All subjects had two or more cranial nerves affected by fungal infection. The most commonly involved cranial nerve was found to be the optic nerve followed by the trigeminal nerve and its branches. We document three cases with extensive involvement of the inferior alveolar branch of the mandibular division of the trigeminal nerve (V3), a previously unreported finding. In one case, in addition to the second and fifth cranial nerves, the third, fourth, sixth, seventh, eighth, and twelfth cranial nerves were involved without any sensory or motor long tract involvement, suggestive of Garcin syndrome secondary to intracranial abscesses and skull base osteomyelitis due to invasive fungal infection. This case is of rare occurrence in the literature, and our study provides one such example. Conclusion: Cranial nerve involvement in patients of mucormycosis tends to have a poor prognosis, both cosmetic and functional. Radical surgeries and aggressive medical management is needed in such cases to improve the outcome.