Large skull base involvement of rhino-orbital-cerebral mucormycosis with rapidly progressive onset in immunocompetent patient mimicking a sphenoid meningioma.

Abstract

Background: Invasive skull base of rhino-orbital-cerebral mucormycosis is rare, rapidly progressive, and potentially life-threatening disease, and it usually occurs in immunocompromised patients. We are witnessing an unprecedented peak of rhino-cerebral mucormycosis since the second wave of the Coronavirus Disease-2019 pandemic.

Case description: A 31-year-old man experienced a sudden onset of decreased visual acuity associated with right exophthalmos and paroxysmal headache that had been ongoing for 2 months before his presentation. On examination, he presented a frontal syndrome with preserved eye movement, with vision impairment, and with bilateral stage 3 papilledema. In addition, the patient is feverish, and the general examination showed no lesion of the nose or skin. All biological investigations were done and were negative, even a COVID-19 test. Brain magnetic resonance imaging revealed a right extra-axial temporal lesion that was isointense on T1-weighted imaging, hypointense on T2-weighted imaging, and well enhancing with gadolinium. The lesion extended into the orbit, cavernous sinus (involving the optic nerve and internal carotid artery), and the infratemporal fossa, suggestive of a sphenoidal meningioma. The patient underwent subtotal resection. Postoperatively, the patient remained feverish, and his condition was worsening. He died 6 days after the surgery. A brain infection was impossible to diagnose until after his death. The anatomopathological examination confirmed mucormycosis.

Conclusion: The findings from the present case indicate that a large intracranial mass is an uncommon clinical characteristic of cerebral mucormycosis in an immunocompetent patient. It can manifest with the classic symptoms of large temporal spheno-orbital invasive meningiomas. To the best of our knowledge, very few studies are reported depicting the patterns of skull base involvement and associated neurological implications of patients with skull base involvement of rhino-orbital-cerebral mucormycosis along with its clinical, radiological, intraoperative, and post-operative correlates.