Control #: 1509 Excerpta #: EE-47 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

To describe early imaging findings of invasive mucormycosis 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 Late findings Black turbinate sign No intracranial invasion at this time Intracranial invasion with non-enhancing and diffusion-restricting brain parenchyma

Black turbinate sign: Imaging review 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