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40. Mucormycosis: “There’s a Fungus Among Us!”
Keywords
MucormycosisZygomycosisSinusitisDiabetesImmunosuppressionCase
Persistent “Orbital Cellulitis”
Pertinent History
A 56-year-old woman with poorly controlled diabetes mellitis (DM) was transferred from an outside hospital due to concern for orbital cellulitis. She was seen at the outside hospital 5 days previously with left-sided ophthalmoplegia, facial numbness, and sinus symptoms. She was evaluated for a possible CVA. After a negative work up, she was discharged on levofloxacin (Levaquin®) with a diagnosis of sinusitis. She had a negative CT scan on the first visit. She returned to the hospital in diabetic ketoacidosis c/o fevers, headache, and loss of vision in her left eye. Following evaluation, she was transferred to the local tertiary care center for further care.
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
HEENT:
Complete ophthalmoplegia/vision loss of left eye, nonreactive to light, proptosis, erythema, and periorbital swelling. Decreased sensation of her left face, some weakness of facial muscles. Necrotic tissue present in the left nares, ecchymotic and partially necrotic palate, and midline uvula.
PMH
DM
Emergency Department Management
Patient’s DKA was managed with insulin and fluids and she was started on Amphotericin. After evaluation by ENT and ophthalmology, she was taken directly to surgery.
Necrotic Tissue in Nostrils and Soft Palate
Used with permission, courtesy of Colin Kaide, MD
Orbital Infection
Used with permission, courtesy of Colin Kaide, MD
Learning Points
Priming Questions
- 1.
What is particular about the pathophysiology of mucormycosis compared to other soft tissue infections?
- 2.
How is mucormycosis diagnosed?
- 3.
Are laboratory and imaging studies helpful in the diagnosis?
- 4.
What is the role of the emergency physician in the treatment of mucormycosis?
Introduction/Background
- 1.
Mucormycosis is a rare but rapid life-threatening infection with a high mortality rate. It is caused by fungal pathogens from the Mucorales order. The most common culprit identified is from Rhizopus species.
- 2.
Overall mortality ranges from 25% to 62%, with the best prognosis in patients with infection confined to the sinuses. Mortality increases with pulmonary involvement and disseminated disease [1].
- 3.
Common underlying conditions that can facilitate this infection [2]:
DM (particularly with ketoacidosis)
Organ or stem cell transplant
Hematologic malignancies
Metabolic acidosis
High dose glucocorticoid treatment
Chemotherapy treatments
Anti-rejection transplant medications
Penetrating trauma/burns
Iron overload states
AIDS
Injection drug use
Malnutrition
Treatment with deferoxamine
- 4.
The host’s immunity and underlying medical condition dictate the clinical presentation of mucormycosis types. From the most to least common: rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and atypical [3]. This review will focus on the rhino-orbital-cerebral presentation, which comprises between 20% and 34% of all cases [4]. The majority of rhino-orbital-cerebral involvement occurs in diabetic patients (about 70%) [5].
Physiology/Pathophysiology
- 1.
Normal host: Phagocytes (mononuclear, polymorphonuclear) → oxidative metabolites + cationic peptides defensins → prevent germination and kill hyphal form.
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