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An 82-year-old man with type 2 diabetes and recent glucocorticoid use presented with a 2-week history of headache and spontaneous bruising around his eye. Black eschars were observed in the nasal cavity (shown in a video).

PurposeTo evaluate serial computed tomography (CT) findings of pulmonary mucormycosis correlated with peripheral blood absolute neutrophil count (ANC).Materials and methodsBetween February 1997 and June 2016, 20 immunocompromised patients (10 males, 10 females; mean age, 48.9 years) were histopathologically diagnosed as pulmonary mucormycosis. On initial (n=20) and follow-up (n=15) CT scans, the patterns of lung abnormalities and their changing features on follow-up scans were evaluated, and the pattern changes were correlated with ANC changes.ResultsAll patients were immunocompromised. On initial CT scans, nodule (≤3cm)/mass (>3cm) or consolidation with surrounding ground-glass opacity halo (18/20, 90%)) was the most common pattern. On follow-up CT, morphologic changes (13/15, 87%) could be seen and they included reversed halo (RH) sign, central necrosis, and air-crescent sign. Although all cases did not demonstrate the regular morphologic changes at the same timeline, various combinations of pattern change could be seen in all patients. Sequential morphologic changes were related with recovering of ANC in 13 of 15 patients.ConclusionPulmonary mucormycosis most frequently presents as consolidation or nodule/mass with halo sign at CT. Morphologic changes into RH sign, central necrotic cavity or air-crescent sign occur with treatment and recovery of ANC.Key points• Pulmonary mucormycosis showed various CT-morphology including CT halo sign• Pulmonary mucormycosis had trends of serial morphologic changes on follow-ups• Recovery of absolute neutrophil count changed CT-morphology of mucormycosis in immune-compromised patients

The halo sign is a CT finding of ground-glass opacity surrounding a pulmonary nodule or mass. The reversed halo sign is a focal rounded area of ground-glass opacity surrounded by a crescent or complete ring of consolidation. In severely immunocompromised patients, these signs are highly suggestive of early infection by an angioinvasive fungus. The halo sign and reversed halo sign are most commonly associated with invasive pulmonary aspergillosis and pulmonary mucormycosis, respectively. Many other infections and noninfectious conditions, such as neoplastic and inflammatory processes, may also manifest with pulmonary nodules associated with either sign. Although nonspecific, both signs can be useful for preemptive initiation of antifungal therapy in the appropriate clinical setting. This review aims to evaluate the diagnostic value of the halo sign and reversed halo sign in immunocompromised hosts and describes the wide spectrum of diseases associated with them.

Abstract Background: Infection with rhino-orbito-cerebral mucormycosis (ROCM) has increased in the coronavirus disease (COVID) era, especially in diabetic patients. Rapid extension from the nose and paranasal sinuses to the orbit and brain is noted by osseous erosion, vascular invasion, and infrequently documented perineural spread. Objective: To determine the incidence of perineural spread in ROCM cases and evaluate the common neural pathways involved, which help in prognosticating and triaging patients. Methods and Materials: We evaluated demographic, clinical, and radiological findings of 270 patients of histopathologically diagnosed ROCM. Imaging signs were used along cranial nerves for diagnosing perineural spread on magnetic resonance imaging (MRI). Results: The perineural spread was observed in 30.4% patients. The most common nerves involved are the infra-orbital (20%), optic (19.2%), and maxillary (16.2%) nerves. Ischemic neuropathy was noted in 13.3% patients, predominantly along the optic nerve. Conclusion: We documented a substantial incidence of perineural spread and common nerves involved in ROCM cases, which has not been previously described in the literature. Perineural spread determines the true extent of disease spread which can bring about better management in this rapidly fatal infection.

ObjectivesTo investigate MRI features in discriminating chronic invasive fungal rhinosinusitis (CIFRS) from sinonasal squamous cell carcinomas (SNSCC).MethodsMRI findings of 33 patients with CIFRS and 47 patients with SNSCC were retrospectively reviewed and compared. Multivariate logistic regression analysis was performed to identify significant imaging features in distinguishing between CIFRS and SNSCC. The ROC curves and the AUC were used to evaluate diagnostic performance.ResultsThere were significant differences in cavernous sinus involvement (p < 0.001), sphenoid sinus involvement (p < 0.001), meningeal involvement (p = 0.024), T2 signal intensity (p = 0.006), and enhancement pattern (p < 0.001) between CIFRS and SNSCC. Multivariate logistic regression analysis identified cavernous sinus involvement (odds ratio [OR] = 0.06, 95% confidence interval [95% CI] = 0.02–0.20) and sphenoid sinus involvement (OR = 0.14, 95% CI = 0.05–0.45) as significant indicators for CIFRS and T2 isointensity to gray matter (OR = 4.44, 95% CI = 1.22–16.22) was a significant indicator for SNSCC. ROC curve analysis showed the AUC from a combination of three imaging features was 0.95 in differentiating CIFRS and SNSCC.ConclusionsMRI showed significant differences between CIFRS and SNSCC features. In immunocompromised patients, a sinonasal hypointense mass on T2WI with septal enhancement or loss of contrast enhancement, and involvement of cavernous sinus, sphenoid sinus, and meninges strongly suggest CIFRS.Key Points• Chronic invasive fungal rhinosinusitis (CIFRS) is often difficult to distinguish from sinonasal squamous cell carcinomas (SNSCC) in clinical practice.• Cavernous sinus and sphenoid sinus involvement appear to be significant indicators for CIFRS. T2 isointensity to gray matter appears to be a significant indicator for SNSCC.• Loss of contrast enhancement and septal enhancement can be used to distinguish CIFRS from SNSCC with a high degree of specificity.

IntroductionMucormycosis are infections caused by molds of the order Mucorales. These opportunistic infections are rare, difficult to diagnose, and have a poor prognosis. We aimed to describe common radiographic patterns that may help to diagnose cerebral mucormycosis and search for histopathological correlations with imaging data.MethodsWe studied the radiological findings (CT and MRI) of 18 patients with cerebral mucormycosis and four patients’ histopathological findings.ResultsAll patients were immunocompromised and/or diabetic. The type of lesions depended on the infection’s dissemination pathway. Hematogenous dissemination lesions were most frequently abscesses (59 lesions), cortical, cortical–subcortical, or in the basal ganglia, with a halo aspect on DWI for lesions larger than 1.6 cm. Only seven lesions were enhanced after contrast injection, with different presentations depending on patients’ immune status. Ischemia and hemorrhagic areas were also seen. Vascular lesions were represented by stenosis and thrombosis. Direct posterior extension lesions were bi-fronto basal hypodensities on CT and restricted diffusion without enhancement on MRI. A particular extension, perineural spread, was seen along the trigeminal nerve. Histopathological analysis found endovascular lesions with destruction of vessel walls by Mucorales, microbleeds around vessels, as well as acute and chronic inflammation.ConclusionsMRI is the critical exam for cerebral mucormycosis. Weak ring enhancement and reduced halo diffusion suggest the diagnosis of fungal infections. Involvement of the frontal lobes should raise suspicion of mucormycosis (along with aspergillosis). The perineural spread can be considered a more specific extension pathway of mucormycosis.

Background Mucormycosis is a rare, rapidly progressive fungal infection caused by molds of the order Mucorales, most commonly Rhizopus species. While it predominantly affects immunocompromised patients, mediastinal mucormycosis is exceptionally rare, with fewer than 50 cases reported, and has a high mortality rate. Diagnosis is challenging owing to nonspecific clinical and radiologic findings, often mimicking malignancies such as lymphoma or thymoma. This study aims to report a rare case of primary mediastinal mucormycosis presenting with hoarseness and to highlight the diagnostic challenges and successful nonsurgical management. Case presentation We report a case of mediastinal mucormycosis in a 76-year-old mainland Chinese man with chronic obstructive pulmonary disease. His initial symptom was progressive hoarseness, likely due to recurrent laryngeal nerve involvement, a rare presentation for mediastinal mucormycosis. Contrast-enhanced chest computed tomography revealed a mass in the left hilar and upper mediastinal regions, suggestive of lung carcinoma. However, a computed tomography-guided mediastinal biopsy confirmed the presence of nonseptate, ribbon-like hyphae, consistent with mucormycosis. The patient was treated with intravenous amphotericin B followed by oral isavuconazole, resulting in marked lesion regression and symptomatic improvement after 6 months of antifungal therapy. In this case, surgery was not attempted because the infection was localized to the mediastinum, making surgical debridement technically unfeasible. Conclusion Mediastinal mucormycosis, though rare, should be considered in patients with atypical presentations including hoarseness, particularly those with chronic illnesses. Early diagnosis through tissue biopsy and timely antifungal treatment is essential for better prognosis.

Purpose To illustrate the imaging findings of orbital compartment syndrome (OCS) in patients with orbital mucormycosis and to identify the red flag signs on imaging for prompt diagnosis and timely intervention. Methods We conducted a retrospective analysis of CT and MRI scans from patients diagnosed with sino-nasal mucormycosis within three months of a confirmed COVID-19 infection. Microbiologically proven cases of mucormycosis were included. Images were analysed for: Route of spread; proptosis; tenting of globe, Retro-orbital fat/extraocular muscle (EOM) nonenhancement; Intra-orbital abscess, superior ophthalmic vein (SOV) thrombosis, stretching/thickening/enhancement/diffusion restriction of optic nerve, orbital coat, and EOM. Descriptive statistics were elaborated in the form of mean/standard deviations for continuous variables and frequencies and percentages for categorical variables. Results Out of 138 patients with mucormycosis, 49 had orbital involvement, OCS was present in 16 orbits. The mean age was 48.6 years with M: F of 2.75:1. Adjacent sinuses were involved in all patients. Spread along nerves and nasolacrimal duct was seen in 94% patients. Globe tenting was seen in all and thickening/coat enhancement in 53.3%. Optic nerve (ON) was thickened in 87.5%, diffusion restriction of ON and EOM in 78.5% cases. Non enhancement of retro-orbital fat was seen in 50% and intra-orbital abscess in 62.5% cases. Conclusions OCS is a vision-threatening orbital emergency, leading to OIS and permanent blindness, if not managed promptly. Imaging features that warrant immediate clinical/ surgical intervention to avoid permanent loss of vision are distorted globe, posterior tenting of the globe, stretching of the optic nerve, non-enhancement of retro-bulbar fat and extra-ocular muscles (EOMs). Key points and clinical relevance statement •Due to overlapping clinical features in the setting of underlying infection, radiologists play a crucial role in detecting OCS in rhino-orbital mucormycosis. •CT and MRI serve as indispensable tools for identification of red flag signs of OCS like globe tenting (“Guitar pick” sign), while non-enhancement of EOM, retro-bulbar fat and optic nerve suggests irreversible damage and development of orbital infarction syndrome (OIS). •A reporting checklist can be handy while interpreting these cases to increase efficiency and avoid missing subtle findings.

Objective: To demonstrate the usefulness of magnetic resonance imaging (MRI) in diagnosing important imaging findings in rhino-orbito-cerebral mucormycosis. Materials and Methods: This is a retrospective cross-sectional study conducted at three medical colleges over 1 month in the patients diagnosed with coronavirus disease 2019 (COVID-19) and who developed mucormycosis of the paranasal sinuses during the treatment and in the post-recovery phase. Results: A total of 95 patients with male preponderance presented with mucormycosis. All had an association with COVID-19 virus disease. All the patients had a history of steroid use during their COVID-19 virus disease treatment. Painful proptosis was present in 42% of patients. The maxillary sinuses (97.22%) were the most commonly affected. Intraorbital extension was observed in 63% of cases, while intracranial extension was demonstrated in 10% of cases. Three patients had perineural spread, and one patient developed a mycotic aneurysm. Conclusions: MRI plays a very crucial role in the prompt and early diagnosis of rhino-orbito-cerebral mucormycosis, as it is used to evaluate the invasion of the disease into the surrounding structures, as well as in preoperative planning for surgical debridement and to ascertain the prognosis. Diffusion-weighted imaging (DWI) adds specificity to localize the path of disease extension by showing restricted diffusion.

Our purpose was to classify acute invasive fungal rhinosinusitis (AIFR) caused by Mucor versus Aspergillus species by evaluating computed tomography radiological findings. Two blinded readers retrospectively graded radiological abnormalities of the craniofacial region observed on craniofacial CT examinations obtained during initial evaluation of 38 patients with eventually pathology-proven AIFR (13:25, Mucor : Aspergillus ). Binomial logistic regression was used to analyze correlation between variables and type of fungi. Score-based models were implemented for analyzing differences in laterality of findings, including the ‘unilateral presence’ and ‘bilateral mean’ models. Binary logistic regression was used, with Score as the only predictor and Group ( Mucor vs Aspergillus ) as the only outcome. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined for the evaluated models. Given the low predictive value of any single evaluated anatomical site, a ‘bilateral mean’ score-based model including the nasal cavity, maxillary sinuses, ethmoid air cells, sphenoid sinus and frontal sinuses yielded the highest prediction accuracy, with Mucor induced AIFR correlating with higher prevalence of bilateral findings. The odds ratio for the model while integrating the above anatomical sites was 12.3 ( p  < 0.001). PPV, NPV, sensitivity, specificity and accuracy were 0.85, 0.82, 0.92, 0.69 and 0.84 respectively. The abnormal radiological findings on craniofacial CT scans of Mucor and Aspergillus induced AIFR could be differentiated based on laterality, with Mucor induced AIFR associated with higher prevalence of bilateral findings.