Case report
Rhinocerebral mucormycosis: Perineural spread via the trigeminal nerve

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Summary

We report a case of rhinocerebral mucormycosis associated with an abscess in the lateral aspect of the pons associated with perineural spread of disease via the trigeminal nerve. Contrast enhanced MRI was useful in depicting the extent of the disease and suggesting perineural spread. A pathological diagnosis of mucormycosis was established by means of rhino-orbital punch biopsy.

Introduction

Rhinocerebral mucormycosis is a devastating fungal infection, which may occur in any immunocompromised host, but it has a predilection for diabetics. The disease process probably starts with inhalation of the fungus into the paranasal sinuses. Upon germination, the fungus may spread inferiorly to invade the palate, posteriorly to invade the sphenoid sinus and beyond into the cavernous sinus, laterally to involve the orbits, or cranially to invade the brain. Multiple clinical syndromes including rhinocerebral, pulmonary, gastrointestinal, cutaneous and disseminated forms have been described.[1], [2]

This case of rhinocerebral mucormycosis associated with an abscess in the lateral aspect of the pons is unusual in its pathway of spread. Perineural spread of disease via the trigeminal nerve is reported only in two other cases in the English literature.

Section snippets

Case report

A 35-year old diabetic man presented with facial pain, swelling and brown discoloration of the right maxillary skin, right proptosis, periorbital edema, ophthalmoplegia and subtotal visual loss. His blood glucose level was 294 mg/dL. Punch biopsy of the nasal mass was reported as mucormycosis.

Magnetic resonance imaging (MRI) revealed soft tissue swelling of the face, obliteration of the right nasal vault, maxillary and ethmoid sinuses, pterygopalatine and infratemporal fossae and suspected

Discussion

Rhinocerebral mucormycosis is a rare opportunistic fungal infection with around 80% of the reported cases occurring in patients with diabetes[1], [3]. It is an acute, often fatal infection caused by fungi of the order mucorales in the class zygomycetes.3

The invasion pattern of cerebral mucormycosis is somewhat predictable and may occur by direct invasion or hematogenous spread. Characteristically the hyphae invade the vessel walls with subsequent local thrombotic infarction.4 This process often

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