Case 1
A 65-year-old diabetic female presented with respiratory distress, left orbital pain, left-sided ptosis, nasal congestion and discharge, and fever of short duration. Reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal swab for COVID-19 was positive.
HRCT thorax (Fig. 1a) revealed multiple peripheral ground glass opacities in posterior subpleural regions of bilateral lung parenchyma with interlobular septal thickening (crazy paving appearance) [9].
CE-MRI of the paranasal sinuses and orbits revealed mucosal thickening and collection in all paranasal sinuses, predominantly in left maxillary (Fig. 1b), sphenoidal, and ethmoidal sinuses. Restricted diffusion on DWI (Fig. 1c) and blooming on GRE (Fig. 1d) were seen involving left middle nasal turbinate and left maxillary sinus. Post-contrast T1-weighted images (Fig. 1e) showed enhancement in the involved structures with area of non-enhancing soft tissue in left middle nasal turbinate and within the left maxillary antrum (“black turbinate sign”) [10, 11]. Retroorbital fat, extraocular muscles of left orbit showed enhancement and inflammation on post-contrast T1 images with left sided proptosis (Fig. 1f).
Histopathological evaluation (HPE) of the nasal discharge revealed broad aseptate ribbon-like fungal hyphae on KOH wet mount [12]. Lactophenol cotton blue (LPCB) stain after 72 h of culture on Sabouraud dextrose agar (SDA) revealed broad aseptate ribbon-like hyphae branching at right angles with sporangium (Fig. 2).
Case 2
A 45-year-old female presented with right hemifacial pain and right orbital swelling for 5 days. Patient had past history of severe COVID-19 pneumonia for which she was hospitalized 3 weeks ago. She was treated with remdesivir, oxygen support, and intravenous methylprednisolone.
CE-MRI of the paranasal sinuses and orbits revealed mucosal thickening and collection in the right maxillary sinus causing blockage of right osteomeatal unit (Fig. 3a). Extension of inflammation with heterogenous post-contrast peripheral enhancement was seen in the right inferior orbital wall (Fig. 3b). Hypertrophied right middle and inferior nasal turbinates. Soft tissue swelling involving the right pre-maxillary soft tissue was seen (Fig. 3c). Mucosal thickening also noted in the ethmoidal and left maxillary sinus (Fig. 3b). KOH mount of nasal discharge revealed broad aseptate fungal hyphae, later confirmed on culture showing broad ribbon-like hyphae with sporangium (Fig. 3d).
Case 3
A 36-year-old male with recent history of COVID-19 pneumonia presented with persisting left hemifacial pain and rhinorrhea.
CE-MRI of the paranasal sinuses, brain, and orbits revealed mucosal thickening and collection involving frontal, ethmoidal, sphenoidal, and left maxillary sinuses (Fig. 4a). Left pre-maxillary soft tissue swelling was seen. Bony defects involving inferior orbital wall was seen with extension of soft tissue component into left inferomedial orbit (Fig. 4b). Small, shrunken left eye globe was seen suggestive of phthisis bulbi [13]. Enhancement involving left infratemporal fossa region and left medial temporal lobe was noted, suggestive of intracranial extension (Fig. 4c).
KOH wet mount revealed broad non septate fungal hyphae. Broad aseptate ribbon-like hyphae with sporangium is seen on the LPCB stain after 72 h of culture in SDA agar (Fig. 4d).