Investigations:
The results of blood chemistry, complete blood count (CBC) and blood gas tests were shown in Table 1. The patient was found to have a high white blood cell count of 11300 mm³ with 91% neutrophils and 7% lymphocytes. Serum chemistry was significant for blood sugar 291mg/dL, bicarbonate 17.8 mEq/L, creatinine 5.4 mg/dL, BUN 46.7mg/dL and lactate dehydrogenase 580 U/L. Laboratory investigations revealed nephropathy and hyperglycemia with diabetic ketoacidosis (DKA).
The COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) test was positive for viral RNA. A chest computed tomography (CT) was performed and revealed bilateral peripheral ground-glass opacification with extensive lung parenchymal involvement (Figure 1). Besides, he was diagnosed with COVID-19 pneumonia. He was classified in severe COVID-19 infection group. After one week, RT-PCR was still positive.
Neurology consulting was performed and brain CT, sinus CT, brain MRI (magnetic resonance imaging), and brain MRA (Magnetic resonance angiography) were ordered. The face CT revealed extensive opacification of right ethmoid, maxillary sinus and nasal septum. There was also obstruction in right ostiomeatal complex (OMC). This can be seen in Figure 2. An MRI and MRA showed that brain tissue was normal (not shown).
To diagnose meningitis, lumbar puncture (LP) was done and cerebrospinal fluid (CSF) was collected to be cultured. The CSF culture was negative for any bacterial infection. However, cytology examination showed acute inflammation in CSF sample.
The clinical and radiographic findings were highly suspicious for acute invasive fungal rhinosinusitis with orbital involvement. Thus, sinuses were debrided and the specimen was sent for culturing and histopathology examination. On histopathology examination, broad aseptate filamentous fungal hyphae was seen and therefore Mucormycosis infection was confirmed.