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Invasive Mucormycosis: A Lesson in the Need for Early Radiographic Diagnosis Control #: 1509 Excerpta #: EE-47 ASNR 2016 Annual Meeting Nathan Wnuk, MD Vaishali Phalke, MD Jeffrey M. Pollock, MD OHSU Portland, OR Disclosures • No disclosures Purpose • To describe early imaging findings of invasive mucormycosis • To illustrate the importance of raising suspicion for invasive mucormycosis when imaging findings are present as the condition can be clinically elusive Case Report Our patient is a diabetic 68-year-old male with relapsed AML who was admitted in his usual state of health for FLAG chemotherapy. • Developed neutropenic fever on day 8 of admission with altered mental status. • MRI of the brain was performed to evaluate for causes of AMS Imaging Findings - MR brain Day 8 • Is there any evidence of fungal sinusitis on this image? Case Report • Left periorbital swelling and mild visual changes were noted on hospital day 12, but were attributed to dependent edema and altered mental status. • The patient's condition deteriorated over the next few days with worsened peri-orbital swelling, vision changes and declining mental status. Case Report • A fungal etiology was considered unlikely based on – repeat negative cultures – sequential sinonasal endoscopies with no findings of fungal disease – sinus mucosal biopsy negative for fungal elements. • Steroid nasal spray decongestion was started on day 17 for suspected bacterial cellulitis/sinusitis. Case Report • The patient’s condition continued to worsen • A CT of the sinuses was obtained on day 17 to re-evaluate sinus disease Imaging Findings – CT Day 17 • Showed bi-frontal edema with parenchymal hemorrhage and worsened orbital inflammatory changes. Case Report • A follow-up MRI brain was obtained the same day Imaging Findings - MR Day 17 • intracranial invasion with extensive frontal lobe and orbital involvement with diffusion restriction and nonenhancement of affected areas. Case Report • The diagnosis of invasive mucormycosis was confirmed on pathology via a transorbital biopsy • Treatment with amphotericin B was initiated • Unfortunately the patient succumbed to infection the following day Imaging review Early findings • Black turbinate sign • No intracranial invasion at this time Late findings • Intracranial invasion with nonenhancing and diffusion-restricting brain parenchyma Imaging review Black turbinate sign: – Mucormycosis is angioinvasive and thrombogenic, causing devascularization of tissue – On contrast enhanced studies the devascularized tissue appears black relative to perfused enhancing tissue Discussion • Mucormycosis is a highly aggressive invasive fungal infection that can be clinically devastating. • Clinical diagnosis is made difficult by low sensitivity of blood and tissue cultures for identifying infection, with as many as 90% of cases not confirmed until post mortem examination. Discussion • Early diagnosis and recognition of initial subtle imaging signs suggestive of the diagnosis may allow for earlier treatment and improved patient outcomes. References • A. Katragkou, T.J. Walsh, E. Roilides, Why is mucormycosis more difficult to cure than more common mycoses? Clinical Microbiology and Infection. 2014;20:74-81 • Skiada, L Pagano, A Groll, et al. Zygomycosis in Europe: analysis of 230 cases accrued by the registry of the European Confederation of Medical Mycology (ECMM) working group on zygomycosis between 2005 and 2007. Clin Microbiol Infect. 2011;17:1859–1867 • MM Roden, TE Zaoutis, WL Buchanan, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis, 2005;41:634–653