Intracranial hypertension: An unusual presentation of mucormycosis in a kidney transplant recipient
A 20-year-old woman, a case of live-related post-renal transplant (haplomatch), of 5-year duration, with underlying chronic allograft nephropathy (on prednisolone 7.5 mg and azathioprine 50 mg) presented with persistent non-throbbing headache, double vision, and inability to read for 3 weeks. Examination revealed blood pressure of 140/90 mm and bilateral papilledema with restriction of left extraocular muscle movements (lateral rectus paresis). Investigations revealed anemia (Hb 8.8 g/dl), mild azotemia (serum creatinine 2.2 mg/dl and urea 57 mg/dl), normal magnetic resonance imaging (MRI), MR venogram of brain, and normal TSH. A diagnosis of IIH was made and was managed with acetazolamide, oral glycerol, escalated prednisolone dose, and antihypertensive, with continuation of basic immunosuppressive drugs.\nOne month later, she reported with pain and swelling in the left half of face and inability to open the left eye. Examination revealed redness and swelling of the left half of her face with eyelid edema, partial restriction of extraocular muscles of the left side, resolving papilledema, and left maxillary sinus tenderness. Computer tomography (CT) scan of paranasal sinuses showed left-sided pan-sinusitis with focal calcification [], and MRI brain confirmed the same in addition to normal neurological structures and cavernous sinus. She underwent fiber optic endoscopic surgery of maxillary, ethmoid, and frontal sinus of the left side. Histopathologic examination of sinus material and culture confirmed zygomycosis []. She was started on amphotericin-B (liposomal) along with continuation of immunosuppressive drugs for next 2 months. During the course of treatment, she developed nodular swelling at inner canthus of left eye, aspirate of which showed broad branches (aseptate hyphae) of Mucor for which exenteration of the eye was suggested but declined by the patient.\nShe was continued on antifungal therapy and received a total of 1.9 g of amphotericin-B over 2 months along with dual immunosuppression. She continued to remain asymptomatic during the last follow-up at 5 years, with regression of the nodular swelling, improvement in vision, resolved papilledema, and stable renal parameters.