Orbital Apex Syndrome Due to Mucormycosis – Missed on Initial MRI

A 64-year-old man with a history of diabetes mellitus and end stage renal disease presented with a several day history of cognitive decline, reduced right eye visual acuity accompanied with a complete right ophthalmoplegia in keeping with orbital apex syndrome. Initial MRI was unremarkable other than mucosal thickening in the frontal sinuses. He continued to clinically decline and repeat MRI revealed an edematous right optic nerve and a lack of enhancement within the sinuses was suspicion for invasive fungal infection. Given his history of diabetes, he was started on anti-fungal treatment and taken for debridement but passed away several days later. This case illustrates the importance of the orbital apex syndrome as a localization. Mucormycosis should be considered in acute onset ophthalmoplegia particularly in patients with diabetes and diabetic ketoacidosis. Empiric anti-fungal therapy should be started early for suspected rhino-orbital cerebral mucormycosis, although mortality remains high despite treatment.