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.