Invasive rhino-orbito-cerebral aspergillosis presenting as multiple cranial neuropathies – A case report

Background and aims: Presenting as a complication of paranasal fungal sinusitis, due to continuous spread of an invasive agent to adjacent tissues, the rhino-orbito-cerebral syndrome is frequently associated with Aspergillus or Mucor infections. Methods: A case of a 66-year-old patient with rapidly progressive cranial neuropathies in the context of an invasive Aspergillosis is presented. Results: A 66-year-old male patient, with a myelodysplastic syndrome and history of recent severe COVID19 infection, was admitted to the Emergency Department due to periorbital pain and fever. On physical examination, the patient displayed III, IV and VI left cranial neuropathies, decreased visual acuity and left hearing loss. A septic thrombosis of the cavernous sinuses was initially admitted and antibiotic therapy started. However, on the following day, peripheral facial diplegia, V2 paresthesia and dysarthria were identified. An MRI was conducted, revealing bilateral ethmoiditis and post-septal left orbital cellulitis, and PAS staining of a nasal biopsy identified spores and hyphae. After admission to an Infectious Diseases unit, the patient clinically deteriorated, with pre- and post-septal cellulitis and progression of periorbital edema to the contralateral eye. A positive PCR test for Aspergillus spp. was detected in the CSF and nasal mucosa. Thirty-one days later, after antifungal therapy (anfotericin B, isavuconazole), clinical improvement was registered. Conclusions: Patients with severe COVID-19, subjected to corticosteroids, are particularly prone to develop fungal infections due to immune system dysfunction. This clinical case highlights the relevance of fungal etiology in the differential diagnosis of ophthalmoplegia in immunosuppressed patients, whose early diagnosis and treatment is essential, excluding potentially fatal infectious.