History of Present Illness:

A patient in their mid-40’s with a history of ocular migraine, DM and ESRD s/p kidney transplant and recent Covid presents to the hospital with 2 weeks of right sided face/head pain followed by 2 days of vision loss in the right eye.  Just recently he noticed low grade fevers up to 100.2 and intermittent mild epigastric pain.  He denies any recent antibiotics or recent travel

Vital Signs & Physical Exam:

Vital signs are normal.  Physical exam is also normal except for mild right CN 6 palsy and no light perception right eye

Initial Diagnostic Testing:

  • CBC: normal but ESR 70
  • Chem-7: glucose 280, Cr. 2.1 otherwise normal
  • Imaging: see below

What is the most likely diagnosis?

  • A) Acute glaucoma
  • B) Cavernous sinus thrombosis
  • C) Ocular migraine
  • D) Malignancy

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What is the most likely diagnosis?

  • A) Acute Glaucoma
  • B) Cavernous sinus thrombosis – CORRECT – CT shows sinusitis, MRI below shoed involvement of orbit as well
  • C) Ocular migraine
  • D) Malignancy

1-Minute Consult on this topic: Click HERE and scroll to page 76

 

CASE CONCLUSION: MRI below shows involvement of right cavernous sinus abutting the carotid artery (black flow void).  ENT did endoscopy which showed a necrotic middle turbinate and pathology showed fungal elements.  She went to the OR and was taken off immune suppressants

CASE CONCLUSION: started on ABX and antifungals and admitted.  Had ENT, ID and neuro consults (sinus surgery image shown below).  Eventually transferred for higher level of care.  Final diagnoses were mucormycosis and orbital apex syndrome.  Remarkably, she survived, which was unexpected.  She did have permanent vision loss in the involved eye.

 

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