A Rare Case of Invasive Mucormycosis in a Diabetic Patient Treated with a Short Course of Dexamethasone

Abstract

Patient: Female, 74-year-old Final Diagnosis: Mucormycosis Symptoms: Altered mental status Medication:— Clinical Procedure: Central venous catheterization • debridement Specialty: Infectious Diseases • General and Internal Medicine • Otolaryngology Objective: Unusual clinical course Background: Invasive mucormycosis is a rare, life-threatening infection that requires urgent medical management. Here we describe a patient who developed invasive mucormycosis after receiving only a short course of dexamethasone. The purpose is to highlight this atypical presentation of a rare disease. Case Report: A 74-year-old woman with a medical history of diabetes mellitus (DM), hypertension, hyperlipidemia, and small cell lung cancer with metastasis to the brain presented to the Emergency Department with altered mental status and a hyperosmolar hyperglycemic state. Three weeks before, she had been diagnosed with DM (hemoglobin A1c [HbA1c] 6.5%) and was started on dexamethasone to treat cerebral edema. On admission, her HbA1c was 10.8%, although she had received only a short course of dexamethasone. Her physical exam was concerning for left eyelid swelling and ophthalmoplegia. Computed tomography of the head and neck revealed signs of left ocular proptosis and invasive rhinomaxillary fungal disease. The patient underwent urgent surgical debridement; subsequent magnetic resonance imaging revealed extensive fungal disease extending into her left inferior frontal lobe. A surgical pathology report was positive for Rhizopus oryzae and Stenotrophomonas maltophilia . Her blood cultures were positive for methicillin-susceptible Staphylococcus aureus . She was treated with antibiotics and amphotericin B. Her clinical course was complicated by hypokalemia. She eventually recovered and was discharged from the hospital. Conclusions: This case highlights an atypical presentation of mucormycosis. Clinicians should remain vigilant for this rare complication of dexamethasone use even when the therapy is given for a short time.

Successful treatment of rhino-cerebral mucormycosis with dual antifungal therapy and minimal surgical debridement

“…The type of infection is characterized by its location: 1) rhino-orbito-cerebral (33–49%), 2) cutaneous (10–16%), 3) pulmonary (10–11%), 4) disseminated (6–12%), and 5) gastrointestinal (2–11%) [12] , [19] , [20] . Rhino-orbito-cerebral is the most common site of infection, potentially because the heme present in red blood cells is an important substrate and the head and neck regions have a rich blood supply [21] . Overall, it has a global mortality rate of about 50% [19] , [22] .…”

“…Other medical risk factors that promote infection include states of iron overload (ie, dialysis, multiple transfusions, cirrhosis, hemochromatosis) [3] , [6] , [9] , [15] , [19] , [37] , [41] , chronic kidney disease [9] , [26] , severe neutropenia [9] , [11] , [12] , [15] , [21] , [22] , [26] , [37] , [41] , transplantation [9] , [22] , [26] , [41] , COVID-19 [4] , [22] , [42] , trauma [9] , [15] , [37] , intravenous drug use [9] , [17] , [37] , neonatal prematurity [6] , [9] , [17] , [26] , [37] , malnourishment [9] , [17] , [37] , and human immunodeficiency virus [17] , [26] . Additionally, mucormycosis has been reported to have a male predominance with a ratio as high as 5:1 [3] , [4] , [7] , [10] , [11] , [23] , [28] , [36] , [38] , [41] , [43] .…”

“…Often the first signs of rhino-orbito-cerebral infection include ophthalmic signs, such as blindness, decreased visual acuity, diplopia, proptosis, and retroorbital pain [2] , [5] , [6] , [7] , [9] , [16] , [19] , [20] , [21] , [28] , [30] , [33] , [37] , [38] , [39] , [43] , [45] , [46] , or sinusitis commonly of the ethmoid and maxillary sinuses, including nasal congestion, epistaxis, and sinus tenderness [1] , [3] , [4] , [7] , [11] , [12] , [14] , [16] , [24] , [35] , [37] , [38] , [43] . Facial weakness, facial swelling, cranial nerve palsy, and facial pain are also typically present [2] , [4] , [5] , [6] , [9] , [11] , [16] , [19] , [20] , [21] , [28] , [30] , [32] , [35] , [37] , [39] , [41] , [43] . Other symptoms may include shortness of breath [37] , fever and chills [16] , [19] , [33] , [37] , headache [2] , [4] , [5] , [16] , [19] , [35] , [45] , and progression of symptoms despite treatment with antimicrobials [26] .…”

“…However, central nervous system involvement and dissemianted infections often require higher doses as well as a longer durations [4] , [8] . With high-dose liposomal amphotericin B, blood urea nitrogen, creatinine, electrolytes, and platelets should be checked regularly during treatment to monitor for amphotericin-related nephrotoxicity, hypokalemia, and thrombocytopenia [19] , [21] , [45] . Posaconazole and isavuconazole can be used as alternatives, salvage therapy, or in combination with amphotericin [1] , [5] , [6] , [18] , [20] , [26] , [31] , [41] .…”

Resolving the equation between mucormycosis and COVID-19 disease

“…However, it is important to mention that amphotericin B has substantial side effects, especially kidney damage (nephrotoxicity). Along with that, its swift administration along with steroid therapy can also lead to hypokalaemia, a condition of low levels potassium (K + ) in the blood serum and may lead to cardiac dysfunction [32][33][34]. Thus, it is evident that a multi-professional squad including ophthalmologist, neurosurgeon, critical care specialist, microbiologist, cardiologists and pathologist is fundamental in successful management of mucormycosis.…”