Blockage results in ischaemia and infarction and this directly produces the characteristic black necrotic eschars seen in this condition. There may be a purulent nasal discharge with dark necrotic material. This damage subsequently generates a more acidotic micro-environment perfect for further fungal growth. This cycle of tissue degeneration, combined with high glucose and fungal entrenchment, fuels the rapid propagation CAL-101 in vitro of the disease.6 Mucormycosis is a rare infection and as such it is hard to calculate the incidence of the infection. However, one American oncology centre revealed that mucormycosis was

found in 0.7% of autopsies and roughly 20 patients per every 100 000 admissions. It is fortunate that it is a rare occurrence but it is crucial that it is not missed. Clinically, the signs and symptoms are non-specific and the extent of

disease at the time of presentation can vary significantly. learn more Like a great deal of rhinological disease, the nose has a limited repertoire of signs to display, making early diagnosis very difficult. However, once the disease takes hold there is seldom any doubt in the mind of an experienced rhinologist. A patient may present with a short history of any of the following: headache, rhinorrhoea, congestion, fever, facial pain, lethargy, epistaxis, eye irritation and lacrimation. On examination the nasal turbinates may appear grey or erythematous and may progress to black necrotic masses or ulceration. Infection can sometimes extend from the sinuses into the mouth and produce painful ulcerations of the hard palate.7 These patients may also have orbital findings and present with periorbital oedema and cellulitis. Invasion of the orbit results in proptosis and chemosis, and with advancing disease complete

ophthalmoplegia and subsequent blindness.8 At this point, the most important thing is to suspect the diagnosis of rhinocerebral mucormycosis (see Figure 1). A delay of even 12 hours in diagnosis may be fatal, as evidenced by the fact that autopsy series have found up to half of cases are diagnosed post-mortem.9,10 Differential diagnoses are listed in Box 1. Differential diagnoses Aggressive Tyrosine-protein kinase BLK inflammatory nasal conditions (e.g. Sarcoid/Wegener’s granulomatosis – ANCA positive vasculitis) T-cell lymphoma (previously known as lethal midline granuloma) Bacterial orbital cellulitis Cavernous sinus thrombosis Aspergillosis Pseudallescheria boydii infection (Pseudallescheriasis) Rapidly growing sino-nasal or orbital tumours Allergic fungal sinusitis Imaging (Figure 2) is extremely useful in evaluating the extent of disease. CT demonstrates thickened mucosa and sinus opacification but, unlike non-invasive sinusitis, there is no respect shown for the normal bony anatomy, and often extensive destruction of the bony boundaries of the nose and sinuses occurs.