Invasive Fungal Sinusitis in Patients With Coronavirus

We enjoyed reading the recent article regarding invasive fungal sinusitis in patients with COVID-19 presenting with multiple cranial nerve palsies (1). At the same time as that report was published, we evaluated a 58-year-old insulin-dependent diabetic woman who was transferred to our medical center late one evening for visual loss and ophthalmoplegia in her left eye.

Letters to the Editor Invasive Fungal Sinusitis in Patients With Coronavirus W e enjoyed reading the recent article regarding invasive fungal sinusitis in patients with COVID-19 presenting with multiple cranial nerve palsies (1). At the same time as that report was published, we evaluated a 58-year-old insulin-dependent diabetic woman who was transferred to our medical center late one evening for visual loss and ophthalmoplegia in her left eye. She had been hospitalized elsewhere 5 days previously for a COVID infection. A brain MRI scan was obtained showing a left orbital abnormality per verbal report (no images or written report available at this time). A bedside examination showed an alert, oriented woman with the visual acuity of 20/100 in the right eye and no light perception in the left eye. Confrontational visual field was full in the right eye. Pupils measured 4 mm in both eyes with normal reactivity in the right eye and a fixed pupil in the left eye. The ocular motility was normal in the right eye and complete ophthalmoplegia in the left eye. The palpebral fissures measured 10 mm in the right eye, and there was complete ptosis in the left eye. There was no proptosis. Trigeminal and facial nerves were intact. The anterior and posterior segments were normal. Brain and orbital computed tomography (CT) and computed tomography angiography of the head/neck were recommended at this time. However, our university was experiencing a COVID surge leading to a delay in neuroimaging. The following morning, the patient became increasingly somnolent and the left fundus showed box-carring of her retinal arteries with retinal whitening indicating profound retinal ischemia. She also had elevated blood glucose values up to 468 mg/dL. We suspected invasive fungal sinusitis (mucormycosis) because she was a poorly controlled diabetic patient; she experienced a change in her cognition and the newly developed fundus findings (2). We consulted infectious disease and otolaryngology head and neck surgery services. Intravenous (IV) vancomycin and extended infusion meropenem and liposomal amphotericin B was promptly initiated, and a bedside nasolaryngoscopy was performed which was normal. A stat brain CT showed extensive opacification of the sphenoid and left ethmoid sinuses and an area of erosion between the sphenoid sinus and the optic canal on the left (Fig. 1). The patient underwent surgery for sinus inspection, biopsy, and debridement revealing necrotic tissue and fungal elements consistent with the genus mucormycosis, class zygomycetes. A subsequent contrasted brain and orbital fat-suppressed MRI showed bilateral sinus, left orbital fat, and optic sheath enhancement (Fig. 2). There were also several small areas of acute supratentorial ischemic changes. The patient has since undergone multiple sinus debridements in addition to antifungal therapy and her Letters to the Editor: J Neuro-Ophthalmol 2022; 42: e607-e608 FIG. 1. Axial bone window CT showing extensive opacification of the sphenoid sinuses and left ethmoid sinus with erosion of the wall of the left sphenoid sinus adjacent to the optic canal on the left (arrow). mental status improved. The ophthalmological examination is unchanged, and she currently remains hospitalized in the intensive care unit. As discussed in the article by Hema et al (1), perhaps the neurotrophic and neuroinvasive qualities of COVID primed the sinus mucosa for fungal invasion into the central nervous system. Our case further emphasizes the need to urgently screen for fungal involvement in patients with COVID presenting with multiple cranial nerve palsies. Given the current FIG. 2. Coronal fat-suppressed gadolinium-enhanced T1weighted orbital MRI showing postsurgical changes of fungal sinusitis debridement, nonenhancing material, presumably necrotic tissue, and orbital and optic sheath enhancement on the left. e607 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Letters to the Editor world-wide COVID crisis and its impact on health care, clinicians need to be more alert to the multiple potential complications of this viral pandemic. Michael S. Vaphiades, DO Danielle Isen, DO Departments of Ophthalmology and Neurology, University of Alabama, Birmingham, Alabama Max Musharoff, MD Lanning B. Kline, MD Department of Ophthalmology, University of Alabama, Birmingham, Alabama Supported in part by an unrestricted grant from the Research to Prevent Blindness, Inc, NY, NY. The authors report no conflicts of interest. REFERENCES 1. Hema VK, Kumar K, Shah VM. Invasive fungal sinusitis in patients with coronavirus disease 2019 seen in south India. J Neuroophthalmol. 2022. doi: 10.1097/ WNO.0000000000001516. Epub ahead of print. 2. 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