A Fungus Among Us

1Tulane, New Orleans, LA
2Tulane, New Orleans, LA
3Tulane, New Orleans, LA
4Tulane, New Orleans, LA

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 144

Case Presentation:

A 38‐year‐old diabetic presented to the emergency room with 2 days of worsening bitemporal headache, diplopia, left facial weakness, and partial left temporal numbness. This constellation of symptoms began while the patient was on a hunting trip in northern Louisiana and had been preceded by sinus congestion. The patient denied ticks bites and medical history other than type 2 diabetes, for which he did not take his prescribed metformin. Physical exam revealed a comfortable, thin man with right eye ptosis, absent lateral gaze, absent right facial sensation, and tachycardia. Laboratory data were significant for a blood glucose of 376, an anion gap of 31, a white blood count of 18,300, and large amounls of urinary glucose and ketones. Magnetic resonance imaging of the brain showed mucoperiosteal swelling of all sinuses, and maxillofacial computed tomography showed left frontal, bilateral ethmoid, maxillary, and sphenoid sinus mucoperiosteal thickening. All other tests were negative including computed tomography of the brain and bacterial, viral, and rickettsial cerebrospinal fluid studies. At this point, the patient was treated for diabetic ketoacidosis and started on broad‐spectrum antibiotics to address the presumed infectious meningitis. On the eighth day of admission, the patient developed a lesion on the roof of his mouth that was black with a necrotic center.

Discussion:

Mucormycosis is a rare but deadly fungal infection with a 60%‐80% mortality rate. Individuals at risk for the development of mucormycosis are immunocompromised patients with a variety of conditions including uncontrolled diabetes, AIDS, steroid therapy, asplenia, neutropenia, leukemias, and other malignancies. Mucormycosis is characterized by the acute onset and rapid progression of nonspecific symptoms including severe headache, proptosis, facial numbness, visual field losses, and cranial nerve deficits. The nonspecific nature of these presenting symptoms often results in delayed diagnosis and poor outcomes. Intracranial mucormycosis treatment is multidisciplinary involving the input from medicine, infectious diseases, neurosurgery, otolaryngology, and maxillofacial surgery specialties. Definitive treatment consists of dead tissue surgical debridement augmented by administration of antifungal medication. Adjunctive hyperbaric oxygen sometimes can be efficacious. Aggressive management of modifiable risk factors like hyperglycemia is also crucial. In the case of our patient, tight glycemic control, antifungal administration, and surgical debridement resulted in our patient returning home with the same degree of visual deficits with which he presented.

Conclusions:

After lesion biopsy the patient was started on amphotericin for presumed mucormycosis, which was later confirmed by pathology. Neurosurgery planned extensive debridement and treatment.

Author Disclosure:

J. Bhutto, none; L. Wasson, none; A. Iqbal, none; S. Bagatell, none.

To cite this abstract:

Bhutto J, Wasson L, Iqbal A, Bagatell S. A Fungus Among Us. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 144. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/a-fungus-among-us/. Accessed September 16, 2019.

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