Volume 3 - Issue 1
Return of the native and a resurrected foe: A case of Rhinocerebral Mucormycosis
R. Niveda*
MRCEM Resident - 2nd year, Department of Emergency Medicine, Kauvery Hospital, Chennai, India
*Correspondence: nivedonut@gmail.com
Case Presentation
A 66 years aged woman presented to our Emergency Department with the complaints of:
Recent and past medical and surgical history:
Known patient of DM\HTN\Hypothyroid\CAD\CKD on medical management.
General Examination
Local examination
Systemic examination
Initial Investigations
CHEM 8 |
CBC |
PTINR |
RFT |
ELECTROLYTES |
Na- 123 |
Wbc-41800 |
PT-19.1 INR- 1.69 |
Urea- 194.8 |
Na- 126.9 |
k- 3.5 |
n-86.4, L-3.3 |
D-DIMER->10,000 |
Crea- 6.4 |
k-3.6 |
cl-95 |
Platelet-2.45lakhs |
PROCAL-6.71 |
Calcium-3.8 |
cl-93.5 |
Ica-0.49 |
|
CRP-287.5 |
Urine spot ca-6.7 |
Bicarb-13 |
BUN-72 |
|
|
LFT-normal |
|
Crea7.7 |
|
VIT D TOTAL 25HYDROXY- 2.9 |
TFT- T3-4.2 T4-3.17 |
|
Glu-277 |
|
|
|
|
Hb-17 |
|
|
|
|
Initially she was treated based on the basic investigations as Urosepsis/septic encephalopathy.
Initial CT Brain and KUB were normal. She was started on broad spectrum antiboitics.
Subsequently, other paramaters (renal function and sepsis) improved but there was no improvement in her GCS (still deteriorating). In view of unexplained drop in her GCS despite treatment, patient underwent MRI brain with MRA.
MRI brain showed acute infarcts in the right medial thalamus, ill-defined soft tissue in right temporal region adjacent to sphenoid sinus with the narrowing of distal cavernous and supraclinoid seg of right ICA, pansinusitis. Contrast MRI was suggested to rule out cerebral abscess.
On suspicion of AFib (embolic infarct!!), she was placed on anticoagulant and antiplatelets.
Accidentally, during the oral suctioning, black necrotic material was noted.
Case discussed with ENT team & planned for nasal endoscopy which showed black necrotic material in inf & middle turbinate. Tissues sent for culture and biopsy; growth showing Mucomycosis in Sabouraud dextrose agar.
Finally diagnosed with rhinocerebral mucormycosis.
However, despite all aggressive measures, she succumbed to the disease.
Fig. 1. MRI Brain - Flair - Infarct involving temporal lobe.
Fig. 2. Cavernous Sinus Thrombosis.
Fig. 3. Pansinusitis.
Culture grow of mucormycosis in Sabouraud dextrose agar
24h of growth
40 h of growth
48 h of growth at 28℃
Microscopic View
Microscopic view of Rhizopus oryzae showing hyphae with spores in 40x focus
View in 100x focus - Rhizopus sp.
Discussion
A complex interplay of factors including preexisting diseases, such as diabetes, hypertension, use of immunosuppressive therapy, and systemic immune alterations of COVID-19 infection itself may lead to the secondary infections, which are increasingly being recognized in view of their impact on morbidity and mortality.
Mucormycosis is generally a group of uncommon infections cause by a fungus but it has become a common diagnosis in post COVID patients. Mucormycosis is an invasive fungal infection once called as zygomycosis, but the organism that cause the infection, which are specific types of molds, have been scientifically reclassified and the term mucormycosis. These infections are broken down into 5 presentations: rhinocerebral, pulmonary, cutaneous, gastrointestinal, and disseminated.
Most common presentation is sinus infection. But when the infection spreads outside the sinuses, it causes necrosis of the roof of the mouth, involve the septum and turbinates, and spreads to brain. This can cause altered consciousness, lethargy, seizures, partial paralysis, neuropathies, brain abscess, and coma.
When the infection spreads to eye there can be swelling, proptosis, vision loss, potentially blindness. In some individuals there could be ophthalmoplegia, making it difficult or painful to open the eyes.
This was a challenging diagnosis because symptoms were common to many other conditions.
When to suspect from warning signs and symptoms:
Conclusion
This is a case of unusual presentation of rapidly developing fungal infection in a patient with preexisting co morbidities in the background of COVID-19.
Increase in mucormycosis in Indian context appears to be an intersection of trinity of diabetes (high prevalence), rampant use of corticosteroids (increases the blood sugar level and opportunistic fungal infections) and COVID-19 (lymphopenia, endothelial damage, cytokine storm).
Learning points
Acknowledgement
I would like to thank Dr. Aslesha (Consultant and Team Lead) and Dr. Vidya for preparing this article.
Dr. R. Niveda
MRCEM Resident
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