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.

Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Background: Mucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%. Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19. Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates. Result(s): This study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001. Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%). Conclusion(s): Mucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.Copyright © 2023, The Author(s).

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.

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.

Guillain-Barre syndrome following COVID-19 vaccination: a case report and an updated review

Background: Coronavirus disease-2019 (COVID-19) has caused a pandemic that has recently affected every aspect of life. Fortunately, many vaccines with high safety and efficacy profiles were developed timely to face this pandemic. In a very short time, billions of people were vaccinated. In the meantime, a wide range of neurological syndromes are being reported. Guillain-Barre syndrome (GBS) which is a rare immune-mediated post-infectious peripheral neuropathy was reported after both the COVID-19 infection itself and many types of its vaccines. Method(s): We are reporting a case of post-AstraZeneca vaccine GBS and reviewing the literature of all reported post-COVID-19 vaccines GBS till July 2021. Result(s): 29 adult patients were reported. Of them 58.6% were males. Their mean age is 58.2 years. The median time to clinical onset after vaccine administration was 13.2 days. 86.2% of patients had their symptoms following immunization with the 1st dose of AstraZeneca vector-based covid vaccine. Facial palsy was the most predominant single symptom in 75.8% of patients. Conclusion(s): Guillain-Barre syndrome is a well-recognized but still rare adverse event following vaccination against COVID-19. Although preliminary data incriminates viral vector-based vaccines more than the other types, active post-vaccination surveillance and more powerful statistics are mandatory to reach a solid conclusion regarding the presence of a causal relation.Copyright © 2022

Critical Review of Covid-19 Associated Mucormycosis of Nose and Paranasal Sinuses in A Tertiary Care Hospital in Ongole, Andhra Pradesh

Background: Mucormycosis is a fungal infection caused by filaments of Mucoraceae which invades blood vessels culminating in a lethal opportunistic infection. During the second wave of COVID-19, all over India a spurt of increased reporting of Mucoraecea infection was experienced. Compromised individual immunity system was suspected. Its early diagnosis and suitable surgical intervention were essential to decrease morbidity and mortality. Aim of the Study: To study the demography, clinical features, risk factors, laboratory investigations, and radiological findings of patients with mucormycosis and to evaluate the clinical outcomes in each case. Materials: A cross sectional study from the Department of ENT of Government Medical College Hospital, Ongole;350 COVID-19 RT-PCR positive patients presented with clinical symptoms and signs of Mucormycosis between February 2021 and February 2022 were analyzed. All age groups and genders were included. Mucormycosis proved on microscopic examination of the aspirate or histopathologies of tissue specimens were included. Clinical findings, risk factors, comorbidities, outcome of the disease, biochemical and hematological investigations, radiological signs, nature of fungal elements isolated, treatment instituted were noted. Surgical procedures included were Functional Endoscopic sinus surgery, extended Endoscopic sinus surgery, Medial maxillectomy, ethmoidectomy, Sphenoid exploration, frontal sinusotomy, Orbital exenteration and Skull base surgeries. Antifungal treatment consisted of administration of liposomal Amphotericin B and posaconazole. Result(s): 350 patients included in this study;268/350 (76.57%) males and 82/350 (23.42%) females with a male to female ratio of 3.26:1. 211 (60.28%) patients living in rural areas and 139 (39.71%) living in the urban areas. 324 (92.57%) patients were positive for COVID-19 (RT-PCR) test and 26 patients were negative. There were 233 (66.57%) patients who were obese with more than 30 BMI index and 117 (33.42%) who were with less than 30 BMI index. 299 (85.42%) patients were diabetic and 51 (14.57%) patients were non diabetic. Vaccination was taken 188 (53.71%) of the patients and not taken by 162 (46.28%) of the patients. Mortality rate was 09/350 (02.57%). It was observed that the variables such as Living area, COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids were significantly associated with Mucormycosis in this study. Conclusion(s): Mucormycosis was found to be common in males, from the rural areas. Other significant risk factors for Mucormycosis were COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids. The most common clinical symptoms and signs among were nasal obstruction with noisy breathing, blood stained nasal discharge, headache, periorbital swelling, reduced vision, Ptosis, external ophthalmoplegia, and facial pains were common. Surgical management reduced the morbidity and mortality of Mucormycosis in this study.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Ophthalmoplegia associated with anti-GQ1b antibodies: case report and review.

A 60-year-old man with longstanding bilateral asymmetrical ptosis presented with a partial third nerve palsy. His diplopia improved following an ice pack test. He did not report any symptoms related to the coronavirus disease 2019 (COVID-19), and nasopharyngeal swab was negative. Initial head imaging and blood work-up were normal except for a high titer of anti-GQ1b antibodies. The patient was subsequently diagnosed with acute ophthalmoparesis without ataxia which is part of the anti-GQ1b antibody syndrome spectrum. He made a spontaneous recovery over the following months without the need for immunotherapy. Clinical features, pathophysiology and a review of the literature are discussed herein. It is important to consider anti-GQ1b antibody syndrome in patients with symptoms of diplopia, ptosis or suspected ocular myasthenia.

Ocular motility disorders following coronavirus disease-19 vaccination.

PURPOSE: To describe clinical manifestations and short-term prognosis of ocular motility disorders following coronavirus disease-2019 (COVID-19) vaccination. METHODS: Ocular motility disorders were diagnosed by clinical assessment, high-resolution magnetic resonance imaging, and laboratory testing. Clinical manifestations, short-term prognosis, and rate of complete recovery were analyzed. RESULTS: Sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22-81 years) were included in this study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0-28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. Among 42 patients with follow-up data (duration: 62.1 ± 40.3 days), complete improvement, partial improvement, no improvement, and exacerbation were shown in 20, 15, 3, and 4 patients, respectively. CONCLUSION: This study provided various clinical features of ocular motility disorders following COVID-19 vaccination. The majority of cases had a mild clinical course while some cases showed a progressive nature. Close follow-up and further studies are needed to elucidate the underlying mechanisms and long-term prognosis.

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.

Sequential orbital apex syndrome following the COVID-19 vaccination: A case report.

Background: Many kinds of vaccines have been developed worldwide to bring the coronavirus disease 2019 (COVID-19) to an end. We report a case of recurrent orbital apex syndrome following the first and third doses of SARS-CoV-2 vaccination. Case presentation: A 71-year-old woman presented with acute painless diplopia and visual disturbance for two days. She had received the first dose of the COVID-19 vaccine two weeks before. She showed decreased visual acuity and ophthalmoplegia in the right eye. An orbital magnetic resonance image (MRI) revealed a hyperintense lesion with enhanced bulging in the right cavernous sinus. Following the steroid pulse therapy, she fully recovered. However, six months after the first attack, painful ophthalmoplegia with decreased visual acuity recurred in her left eye after the booster vaccination for COVID-19. MRI also showed a well-enhanced hyperintense lesion in the left orbital apex. Fortunately, her visual acuity and ocular motility returned to normal after the steroid therapy. Conclusions: Immunologic reactions from COVID-19 vaccines may cause multiple cranial neuropathies. Diverse individual immunologic states should be considered before any kind of vaccine.

Mortality and its determinants after an outbreak of post COVID-19 associated rhino-orbito-cerebral mucormycosis in Central India.

AIM: To report cumulative mortality rates using survival analysis from an outbreak of 211 patients with post COVID-19 rhino-orbito-cerebral mucormycosis (ROCM) in central India. METHODS: Case files of eligible patients were evaluated and mucor was identified from deep nasal swabs using freshly prepared KOH mount. All patients underwent contrast enhanced MRI and disease staging was done based on the extent of anatomical involvement. All patients received intravenous Amphotericin B and sinus debridement was done when possible. Orbital exenteration was reserved for patients with advanced orbital disease. RESULTS: The mean age was 50.7 ± 10.2 of which 147 (70%) were men. At presentation, ROCM was limited to sinuses in 72 (34%), orbital extension was seen in 102 (48%) and 31 (15%) had CNS extension. Sinus debridement was possible in 82% cases (n = 173). Thirty-five (16.6%) patients died due to ROCM. The mean follow-up of patients who survived was 126.6 ± 16.4 days. The cumulative mortality rate at day 10 was 4.8% (95%CI = 2.6-8.8%) and increased 13.1% (95%CI = 9.1-18.7%) at day 30 and to 18.4% (95%CI = 13.6-24.8%) at day 60. Majority of deaths (n = 26, 75%) occurred within 1-month of ROCM presentation. Multivariable hazards analysis showed that patients with CNS involvement had a 6.5 times higher risk of death (Hazard Ratio = 6.71, 95% CI = 2.9-15.5, p < 0.001). CONCLUSION: We report significantly lower mortality rates compared to recent literature that varies from 30 to 80% at 1-month follow-up. Timely sinus debridement and systemic Amphotericin B can help reduce mortality. Presence of CNS extension significantly increased the mortality risk with patients with ROCM.

Abstracts of the 52nd Annual Conference of the Italian Society of Neurology

The proceedings contain 1146 papers. The topics discussed include: successful treatment of chronic migraine comordids with myasthenia gravis and arthritis with monoclonal antibody against CGRP: a case report;atypical presentation of anti neurofascin-155 autoimmune nodopathy;descriptive study on the correlation between visual and auditory evoked potentials associated with visual and auditory P300S using wavelet analysis of individual traces in normal, MCI and SDAT subjects;hemispheric EEG asymmetry in depressive disorders and control subjects using Loreta data analysis;co-occurrence of dermatomyositis and myasthenia gravis after Covid-19 vaccine: a case report;tonic-clonic seizures in a patient with pseudohypoparathyroidism: a case report;childhood case of glycogenosis type 2 with abnormal capillaries and autophagy block;long-term misdiagnosis of MS in a patient with MOGAD: clinical and therapeutic implications of a correct diagnosis;abnormal brain stress-response: a lesson learned from a febrile infection;and an ultra-rare mediastinal vascular sarcoma in a patient with chronic ophthalmoplegia (CPEO) and mitochondrial myopathy due to deoxyguanosine kinase (DGUOK) deficiency: a case report.

Miller-Fisher syndrome after first dose of Oxford/AstraZeneca coronavirus disease 2019 vaccine: a case report.

INTRODUCTION: Miller-Fisher Syndrome (MFS) is a variant of Guillain-Barré syndrome (GBS), an acute immune-mediated neuropathy, which manifests as a rapidly evolving areflex motor paralysis. This syndrome presents as a classic triad: ophthalmoplegia, areflexia, and ataxia. MFS is usually benign and self-limited. CASE REPORT: A Caucasian patient was admitted to our hospital with the flu, loss of bilateral strength in the lower limbs and upper limbs and sudden-onset ataxia 7 days after receiving a first dose of the Oxford/AstraZeneca COVID-19 vaccine. On neurological examination, the patient had Glasgow Coma Scale score of 15, with absence of meningeal signs; negative Babinski sign; grade 2 strength in the lower limbs and grade 4 strength in the upper limbs; axial and appendicular cerebellar ataxia; and peripheral facial diparesis predominantly on the right, without conjugate gaze deviation. Cerebrospinal fluid (CSF) was collected on admission, and analysis revealed albuminocytological dissociation with CSF protein of 148.9 mg/dL; leukocytes, 1; chlorine, 122; glucose, 65 mg/mL; red cells, 2; and non-reactive venereal disease research laboratory test result. The COVID-19 IgG/IgM rapid immunological test was negative. Electroneuromyography revealed a recent moderate-grade and primarily sensory and motor demyelinating polyneuropathy with associated proximal motor block. DISCUSSION AND CONCLUSION: Miller-Fisher Syndrome may be related to events other than infections prior to neuropathy, as in the case reported here. The patient presented strong correlations with findings for MFS reported in the literature, such as the clinical condition, the results of electroneuromyography, and results of the CSF analysis typical for MFS. When treatment was provided as proposed in the literature, the disease evolved with improvement. Ultimately, the diagnosis of incomplete MFS was made, including acute ataxic neuropathy (without ophthalmoplegia).

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.

COVID-19 provoked internuclear ophthalmoplegia in a child with arrested hydrocephalus.

Internuclear ophthalmoplegia (INO) is a neuro-ophthalmic disorder caused by damage in the medial longitudinal fasciculus between the third and sixth cranial nerve nuclei. We present a 4-year-old female diagnosed with INO triggered by coronavirus disease 2019 (COVID-19) infection. The patient had history of neonatal meningitis with hydrocephalus without history of surgical intervention. To the best of our knowledge, this is the first case with combined COVID-19 and chronic hydrocephalus as an etiology for INO in a child. COVID-19 may trigger neurological manifestations as INO in susceptible cases.

45th Annual Meeting of the American Society of Neuroimaging

The proceedings contain 31 papers. The topics discussed include: brain abscess appearing 20 years post craniotomy;postoperative diffusion restriction in the proximal optic nerve: optic neuropathy or central retinal artery occlusion?;magnetic resonance imaging as a prognostic disability marker in clinically isolated syndrome: a systematic review;bilateral internuclear ophthalmoplegia caused by unilateral infarction;neuroaspergillosis in a patient with chronic lymphocytic leukemia as progressively worsening ischemic infarct;neuroimaging in mitochondrial short-chain enoyl-coa hydratase 1 deficiency: a progressive encephalomyelopathy starting in utero;childhood-onset neurodegeneration with brain atrophy: imaging findings of a rare diagnosis;multiple sclerosis associated with Balo-like lesions post-coronavirus disease 2019;and within-subject reproducibility of quantitative proton density mapping.

COVID-19 Vaccination May Provoke Intracranial Hypertension

In parallel to the spread of the novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), there has been the growing recognition that active SARS-CoV-2 infection has the potential to effect both the peripheral and central nervous systems. When it comes to the SARS-CoV-2 vaccine, however, reporting has been more uncertain. As the vaccination rate has risen, we have seen a rise in rare neurological complications thought to be associated with the vaccination including acute transverse myelitis, Guillain-Barre syndrome, optic neuritis, and Tolosa-Hunt syndrome. The Centers for Disease Control and Prevention (CDC) estimates 98 confirmed cases of Guillain-Barre syndrome out of 12.6 million doses. Given the initial age limits of vaccination eligibility, most reports have been limited to the adult population. Here, we report a case of intracranial hypertension (IH), evolving to fulminant IH in a healthy female after receiving the SARS-CoV-2 vaccine. While elevated intracranial pressure has been reported in the context of active SARS-CoV-2 infections and postinfection multisystem inflammatory syndrome (MIS-C), this is the first reported case of pediatric IH after vaccination alone.

ANOTHER COMPLICATION OF COVID-19?: A CASE OF RHINOORBITAL-CEREBRAL MUCORMYCOSIS

CASE: A 44-year-old male with past medical history of type II insulindependent diabetes mellitus (DM) and end stage liver disease (ESLD) due to alcohol use and nonalcoholic fatty liver disease (NAFLD) presented with one week of left-sided retroorbital headache and diplopia. Two weeks prior, the patient tested positive for COVID-19 and initially his severe headache was attributed to this diagnosis. On hospital presentation the patient was found to have ophthalmoplegia, ptosis and diminished sensation in the CN V1 distribution on the left. The patient was in diabetic ketoacidosis (DKA) with glucose of 686, venous blood gas of 7.32/29/15 and serum anion gap of 17. Contrasted orbital and maxillofacial CT showed complete opacification of the left sphenoid sinus and CT angiography/venography of the head were negative for venous sinus thrombosis. MRI of the brain showed left optic nerve ischemia and left frontal lobe cerebritis without abscess. Bedside nasal endoscopy with ENT showed purulent, fuzzy white debris bilaterally concerning for fungal sinusitis. He was taken urgently to the operating room and was found to have angioinvasive fungal sinusitis with cultures growing Lichthemia corymbifera, a fungus in the Mucor family. In addition to treatment with IV insulin and fluids for DKA, the patient was given amphotericin B and posaconazole;however, surgical intervention was deemed too high risk and futile in the setting of patient's comorbidities. IMPACT/DISCUSSION: Mucormycosis is a fungal infection that typically involves the sinuses, orbits and the central nervous system (CNS). Infection of the sinuses manifests with fever, sinus congestion/pain and headache, but can rapidly progress to involve the orbits, leading to vision changes, and the CNS, leading to encephalopathy. Other structures that can be involved include the cavernous sinus, leading to palsies of cranial nerves III-VI. Known risk factors for mucormycosis include DM, especially in patients with DKA, glucocorticoid treatment, immunosuppression and deferoxamine use. Urgent histopathologic diagnosis, initiation of intravenous antifungal agents (amphotericin B) and surgical intervention with ENT, ideally prior to extension beyond the sinuses, are fundamental to decreasing mortality, which is as high as 62%. There have been numerous case reports of mucormycosis in patients with COVID-19, particularly from India. Many of these patients were prescribed glucocorticoids as part of the COVID-19 treatment pathway or had underlying DM. Additional research is needed into the association between COVID-19 and invasive mucormycosis. CONCLUSION: In patients with poorly controlled DM or immunosuppression presenting with severe headache, sinus pain, and/or neurologic changes, mucormycosis must be considered, as it is a fatal entity requiring urgent surgical intervention and initiation of antifungal agents. Patients with COVID-19 infection may be at increased risk for mucormycosis, especially in those with underlying DM or on glucocorticoids.

COVID-19 Presenting As Miller Fisher Syndrome in a Patient With a History of Guillain-Barré Syndrome: A Case Report.

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, primarily affects the respiratory system. While coronaviruses are not a common cause of neurological disease, they have been reported to cause direct central nervous system infection, as well as presumed para-infectious disorders. Here we report a very rare case of SARS-CoV-2 infection presenting as Miller Fisher syndrome with positive anti-GQ1b antibodies in a patient with a history of Guillain-Barré syndrome, which was treated with IV immunoglobulin resulting in marked improvement in her symptoms. Thus, a high index of suspicion and meticulous observation are the cornerstones to identifying possible uncommon presentations of COVID-19.