Rhino-orbital-cerebral mucormycosis (ROCM) is the most common manifestation of mucormycosis in uncontrolled diabetes and diabetic ketoacidosis (DKA). This infection is extremely aggressive, invading blood vessels and spreading quickly from the sinuses to the orbit and brain. We present a case of a 57-year-old male with poorly controlled type 2 diabetes who came to the hospital with facial swelling, blurry vision, and severe DKA. Imaging revealed orbital cellulitis, sinusitis with gas formation, and cavernous sinus thrombosis. He underwent an urgent lateral canthotomy and surgical debridement. Pathology confirmed invasive mucormycosis, and he was started on liposomal amphotericin B. Despite aggressive treatment, the infection progressed to the brain, causing multiple strokes. The patient's condition continued to decline, and he was eventually transitioned to hospice care. This case emphasizes the importance of early recognition of mucormycosis in high-risk patients to prompt urgent evaluation. Because the infection spreads so rapidly and antifungal medications penetrate the brain poorly, early surgical intervention and systemic therapy are vital.

Chronic relapsing inflammatory optic neuropathy (CRION) is a rare cause of recurrent optic neuritis characterized by steroid responsiveness and relapse upon treatment withdrawal. Because no definitive diagnostic test exists, the diagnosis is clinical and requires exclusion of more common demyelinating and antibody-mediated disorders. We describe a 45 year-old woman with a history of psoriasis, photodermatitis, and Hashimoto thyroiditis who presented with four episodes of severe left retro-orbital pain and progressive visual blurring over a three-year period, with the right eye remaining unaffected throughout. Each episode demonstrated left optic nerve enhancement on magnetic resonance imaging and responded promptly to intravenous corticosteroids. Extensive evaluation for multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein (MOG) antibody disease was consistently negative. A diagnosis of seronegative CRION was established based on the recurrent steroid-responsive clinical pattern. Long-term immunosuppressive therapy with mycophenolate mofetil, later transitioned to mycophenolic acid due to gastrointestinal intolerance, resulted in clinical stability during follow-up. One additional relapse occurred following a brief three-day interruption of mycophenolate for treatment of cellulitis. CRION should be considered in patients with recurrent optic neuritis when workup for demyelinating and antibody-mediated conditions is negative. Early recognition and initiation of long-term immunosuppressive therapy are important to reduce relapse frequency and prevent cumulative optic nerve damage.

To report the second case report in the literature of early-onset endophthalmitis caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) after penetrating keratoplasty (PK). The associated diagnostic and therapeutic challenges are highlighted, and the precautions that can be applied are emphasized. A 69-year-old woman with bullous keratopathy underwent elective PK. Within 24 hr postoperatively, stromal infiltration and partial separation at the superior quadrant of the graft and anterior chamber reaction were observed. Urgent rekeratoplasty was performed, and microbiologic culture of the donor tissue revealed extensively drug-resistant CRKP resistant to multiple antibiotics. Despite rapid surgical revision and intensive antimicrobial therapy (topical, intrastromal, intravitreal, and systemic), the infection progressed to orbital cellulitis and systemic involvement, ultimately requiring evisceration. Carbapenem-resistant Klebsiella pneumoniae was also isolated from the excised globe. Donor-derived contamination was strongly suspected because of the early clinical course but could not be confirmed microbiologically because the donor margin tissue was not preserved. Furthermore, retrospective medical data review of the donor did not reveal any similar microorganism and clinical follow-up of PK from the other corneal partner showed no infection. This case constitutes the second documented instance of CRKP-related endophthalmitis after PK in the literature. It emphasizes the importance of donor screening, continuous monitoring of the storage environment, preservation of donor margin tissue, and vigilant monitoring for systemic dissemination and severe postoperative complications.

IntroductionOrbital involvement is a serious complication of ethmoiditis in children, often occurring because the ethmoid sinuses are very close to the orbit. Our work aimed to report the clinical presentation, treatment modalities and the outcome of orbital complications of acute ethmoiditis to identify common indicators for surgery.MethodsRetrospective observational study to review cases that were hospitalized in pediatrics and otorhinolaryngology departments of the Farhat Hached Hospital in Sousse, Tunisia, during the period from January 2013 to December 2023.ResultsWe collected 79 cases. The mean age was 4,55±3,64 years old. Five of our patients had anemia, six had allergic rhinitis, and one had asthma. Two other patients had undergone recent dental care. Palpebral edema and fever were the most frequently reported symptoms. A palpebral abscess was present in five cases, while nineteen cases exhibited exophthalmos. Seven children had limited occulomotricity, and one child had ophthalmoplegia.In addition, reduced visual acuity was reported in 3 cases. Referring to Chandler's stratification, we report 37 cases of preseptal cellulitis, 10 cases of orbital cellulitis and, 31 cases of subperiosteal abscess. Eleven patients required surgical treatment consisting of orbitotomy. Age equal to or above 5 years old was more associated with surgical treatment (p<0.001). The outcome was generally favorable.ConclusionOrbital complications of acute ethmoiditis are a low-prevalence high risk disease. Most patients are successfully treated without long-term complications. Younger children (<5 years) are less likely to undergo surgery.

Extranodal natural killer/T-cell lymphoma (ENKTL) is a rare and aggressive form of non-Hodgkin lymphoma. It most commonly affects the nasal cavity and sinuses. While only few of cases of third cranial nerve palsy have been reported in association with diffuse large B-cell lymphoma and Burkitt lymphoma, its occurrence as a presenting feature of ENKTL is exceptionally rare. Here, we present a patient with isolated third cranial nerve palsy as the initial manifestation of relapsed ENKTL. A 67-year-old woman with a history of ENKTL in remission was admitted with bilateral periorbital swelling, nasal purulent discharge, and congestion following nasal reconstruction. She was diagnosed with preseptal cellulitis and sinusitis and subsequently treated with IV antibiotics. She later developed a right third nerve palsy with pupillary involvement. A CT angiogram ruled out an aneurysm, however brain MRI showed perineural spread affecting the cavernous sinus. Further cranial nerve involvement prompted a biopsy of the sinus, confirming ENKTL. A PET scan was done. No uptake in the brain, sinuses, or the rest of the body was observed. A bone marrow biopsy was subsequently performed revealing marrow involvement with ENKTL, suggesting metastatic spread beyond the sinuses. Unfortunately, the patient developed sepsis and subsequently passed away. This case emphasizes the importance of early consideration of malignancy who present with atypical neurological symptoms. Given the risk of false-negative imaging results, a multimodal approach is essential. This should include high-resolution MRI coupled with neuroradiological review, biopsy with histopathological analysis when feasible, FDG PET scan and lumbar puncture with CSF analysis.