Teaching NeuroImages: Mucormycosis-associated vasculitis ~A new sequence to show an old invasive infection~

Summary

Terminology

Original

  • 54yo F
  • C/C
    • HIV infection
      • headache
      • nasal discharge
      • ophthalmoplegia for 1mo
  • PMHx
    • DM
  • Ex
    • CSF
      • Lym pleocytosis
    • Histo
      • mucormyosis

A diabetic 54-year-old woman with HIV infection presented headache, nasal discharge, and ophthalmoplegia for 1 month. CSF showed lymphocytic pleocytosis. CT disclosed invasive sinusopathy. Histopathologic analysis confirmed mucormycosis (figure 1). Angiography with high-resolution vessel wall imaging (HR-VWI) was performed (figure 2). She died despite surgical debridements and treatment with liposomal amphotericin B.

Figure 1

Axial CT scan discloses soft tissue in ethmoidal cells and sphenoid sinus with erosion of lamina papyraceae
(A, B) There is extension of inflammatory process to orbits.
(C, D) Necrotic tissue invaded by large and nonseptate hyphae, consistent with mucormycosis (×40).

Fig.1

Figure 2

3D time-of-flight magnetic resonance angiography and volume rendering reconstruction depict left carotid artery (LCA) stenosis and infectious pseudoaneurysms
(A, B) High-resolution vessel wall imaging postcontrast demonstrates a concentric thickening of LCA.
There is inflammatory process in inner layer and probable area of necrosis in outer layer. There is also septic thrombosis in left cavernous sinus (C, D).

Fig.2

HR-VWI is useful in vasculitis evaluation due to its ability to demonstrate enhancement in the area of inflammation.1,2 In this case, smooth and concentric vessel wall enhancement related to inflammation was observed. Further studies are required to determine the accuracy of this method for mucormycosis.