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:

  1. Decreased sensorium and drowsiness for 2 days
  2. Decreased oral intake for 2 days

Recent and past medical and surgical history:

Known patient of DM\HTN\Hypothyroid\CAD\CKD on medical management.

  1. k/c/o Acute pyelonephritis for which underwent cystoscopy with B/L DJ stenting.
  2. Recent COVID pneumonia
  3. Urinary tract infection

General Examination

  1. Patient conscious, drowsy, arousable, pallor present
  2. VITALS: HR: 116/min, BP: 110/60 mmg, SPO2: 100% RA, RR: 30/min

Local examination

  1. Facial puffiness +, lips edematous, Oral cavity: teeth stained, crusting +, foul smelling (Halitosis)+

Systemic examination

  1. Respiratory system: B/L Breath sounds reduced, B/L crepts +
  2. CVS: S1, S2 +, no murmer, JVP normal
  3. Abdomen: soft, non tender, no organomegaly, BS +
  4. CNS: GCS – E2V2M5, No deficit

Initial Investigations

  1. ECG: sinus tachycardia
  2. ABG: showed high anion gap metabolic acidosis with compensation
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        
  1. CT Brain: age related atrophy
  2. CT Chest: patchy GGO in b/l peripheral subpleural location, s/o atypical infection, CORADS- 5 – severity score:14/25

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.

  1. CT BRAIN with CONTRAST indicated the following:
  2. Acute infarct in right gangliocapsular region.
  3. Cavemous sinus thrombosis.
  4. Pansinusitis
  5. Right temporal lobe abscess.

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.

  

 

temporal-lobe

 

Fig. 1. MRI Brain – Flair – Infarct involving temporal lobe.

 

Cavernous-Sinus-Thrombosis

 

Fig. 2. Cavernous Sinus Thrombosis.

 

Pansinusitis

 

Fig. 3. Pansinusitis.

Culture grow of mucormycosis in Sabouraud dextrose agar

Culture-grow
24h-of-growth24h of growth

40-h-of-growth40 h of growth

48-h-of-growth48 h of growth at 28℃

Microscopic View

Microscopic
Microscopic-View

 

Microscopic view of Rhizopus oryzae showing hyphae with spores in 40x focus

 

Rhizopus

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:

  1. Sinusitis: nasal stuffiness/erythematous nasal mucosa, nasal discharge (bloody/blackish), local pain on cheek bone, epistaxis, loss of smell.
  2. One sided facial pain, numbness/paresthesia, or swelling,
  3. Halitosis, Tooth ache, loosening of teeth, jaw involvement, palatal ulceration.
  4. Eyelid edema, orbital pain, eyelid ptosis, protruding eyes, ocular mobility restrictions, double vision and sudden vision loss.
  5. Fever, headache, cough, shortness of breath, altered mental state, thrombosis and necrosis (eschar formation).
  6. Chest pain, pleural effusion, haemoptysis.

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

  1. An effective teamwork is an essential tool for constructing a more effective and patient-centered health care delivery system (Emergency physicians, internal medicine specialist, intensivist, ENT specialist, neurologist, ophthalmologist, microbiologist, dentist, and surgeon).
  2. We have evidence that steroids are indicated in reducing mortality in COVID-19 patients with low oxygen saturation levels. Steroids reduce inflammation; however, they also have an immunosuppressive action, impacting the ability to fight infection.  It is important to use it at the right time, in the right dose and for the right duration.
  3. Early diagnosis and treatment of mucormycosis that involve antifungal therapy and surgical debridement are necessary to reduce mortality and prevent the end-organ damage.
  4. Use clean, sterile water for humidifiers during oxygen therapy
  5. Do not consider all the cases as bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators
  6. Do not hesitate to seek investigations, as appropriate such as KOH staining & microscopy, cultures for detecting fungal etiology.

 

Acknowledgement

I would like to thank Dr. Aslesha (Consultant and Team Lead) and Dr. Vidya for preparing this article.

 

Dr-R-Niveda

Dr. R. Niveda

MRCEM Resident

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