2 Figure 1: A 43 year-old man aﬀected by zygomycosis and bilateral facial nerve paralysis. Figure 2: Neck CT scan of the case shows multiple cystic lesions in the neck and right parapharyngeal space. ear ﬂuid just showed inﬂammatory changes. Comprehensive immunologic evaluation including measurement of serum immunoglobulins, serum protein electrophoresis, human immunodeﬁciency virus (HIV) antibodies, antihuman T- lymphotropic virus type 1 and 2 antibodies, lymphocyte transformation time, bone marrow aspiration and trephine biopsy, and ﬂow cytometry for determination of lymphocyte subpopulations was performed. There was a cell mediated immune deﬁciency with unknown cause including decreased natural killer cells, decreased T helper cells (CD4+) and increased T suppressor cells (CD8+). The patient received amphotericin B up to 3 grams. Results of repeated HIV test after 6 and 12 months were also negative. After one-year follow-up, he has been survived with no evidence of systemic or immunologic diseases or recurrence. Informed consent was obtained from the patient for printing his anonymous photos. Case Reports in Medicine 3. Discussion Rhino-orbital-cerebral zygomycosis is most commonly caused by Rhizopus oryzae [1]. This infection aﬄicts pri- marily diabetics and other immunocompromised patients. In rare occasions it can infect normal hosts [2]. Our case had no obvious underlying disorder except a cell-mediated immune deﬁciency with unknown cause. There are few cases of zygomycosis in the literature secondary to various type of cell-mediated immunodeﬁciency [3]. Cyst formation in zygomycosis is very rare and has been reported as orbital or brain abscess in the literature [4]. The role of T cells in mediating protection against abscess formation by some bacterial species has been described [5]. However, the protective role of T cells in abscess formation by fungi in the cell-mediated immune deﬁciency is not clear now. Hearing impairment has been reported in 3.5% of cases in one study [2]. More reports cited facial nerve paralysis in conjunction with rhino-orbital-cerebral zygomycosis [6] with reported frequency of 11% [2]. According to our knowledge, there is no case of bilateral complete facial paralysis in the literature. No obvious pathophysiology for facial nerve paralysis has been proposed yet. Some researchers believe that infection can reach from the pterygopalatine fossa to inferior orbital ﬁssure, orbital apex, and infratemporal fossa [6]. Whether or not the facial nerve is involved at stylomastoid foramen via mentioned pathway is not completely obvious. There is a need to conduct more studies regarding common spread pathways of rhino-orbital-cerebral zygomycosis with presumptive implication in more directed debridement procedures in early stages of the disease. References [1] G. M. Cox, “Zygomycosis (mucormycosis),” in UpToDate, D. S. Basow, Ed., UpToDate, Waltham, Mass, USA, 2009. [2] B. J. Ferguson, “Mucormycosis of the nose and paranasal sinuses,” Otolaryngologic Clinics of North America, vol. 33, no. 2, pp. 349–365, 2000. [3] M. Bongiovanni, R. Ranieri, D. Ferrari, C. Codeca`, T. Tartaro, and L. Uziel, “Prolonged survival of an HIV-infected subject with severe lymphoproliferative disease and rhinocerebral mucormycosis [14],” Journal of Antimicrobial Chemotherapy, vol. 60, no. 1, pp. 192–193, 2007. [4] N. Mnif, E. Hmaied, S. Oueslati et al., “Imaging of rhinocere- bral mucormycosisL’imagerie dans la mucormycose rhinoce´re´- brale,” Journal de Radiologie, vol. 86, no. 9, part 1, pp. 1017– 1020, 2005. [5] A. O. Tzianabos and D. L. Kasper, “Role of T cells in abscess formation,” Current Opinion in Microbiology, vol. 5, no. 1, pp. 92–96, 2002. [6] S. M. S. Hosseini and P. Borghei, “Rhinocerebral mucormy- cosis: pathways of spread,” European Archives of Oto-Rhino- Laryngology, vol. 262, no. 11, pp. 932–938, 2005.