A 66-year-old lady presented to our emergency department with the following complaints:
The patient is a known case of having diabetes, hypertension, coronary artery disease, and chronic kidney disease on medical management with a baseline keratinize of 2.1 mg/dl. She has also hypothyroid.
General examination – Patient conscious, drowsy, arousable – Pallor present – No icterus/clubbing/cynosis/lymphadenopathy/edema. – Vitals: HR: 116/min, BP: 110/60mmg, SPO2: 100%RA, RR:30/min
Local examination:
– Facial puffiness + lip edema – Oral cavity : teeth stained, crusting + , foul smelling(halitosis)+
Systemic examination
I. Respiratory system: B/L air entry decreased, B/L crepts + II. Cardiovascular system: S1, S2 +, no murmer, JVP normal III. Abdomen: soft, non-tender, no organomegaly, BS + IV. Central nervous system: GCS- E2V2M5, no deficit
Initial investigations and workup
ECG: sinus tachycardia ABG: showed high anion gap metabolic acidosis with compensation
Serology: NEGATIVE Urine routine: Turbid, pus cells: 10-12, u.protein: +, u.blood: ++, ketone : negative, crystal and cast : nil Blood culture: no growth Urine culture: GNB: E-coli CT brain: age-related atrophy CT chest: patchy GGO in b/l peripheral subpleural location s/o atypical infection CORADS- 5 – severity score: 14/25 CT – KUB: no significant abnormality
ECHO : conc LVH, normal RV &LV EF-60%, no RWMA, mild PAH—EEG: no epileptic features Primarily, the case was treated based on the initial investigation as urosepsis with acute kidney on chronic kidney injury and was started on IV antibiotics, PPI. Hemodialysis was done at the ICU stay. Initial CT brain and KUB were normal. Subsequently, on day 3 of hospitalization, sepsis improved, and kidney injury was also resolving with hemodialysis, but there was no improvement in her GCS, which was still deteriorating. Hence, the patient was put on NIV as she was tachypneic and tachycardiac. She was continued with broad-spectrum IV antibiotics. In view of unexplained drop in GCS despite treatment, the patient underwent an MRI brain with MRA. – MRI brain with MRA: Acute infarcts were found in the right medial thalamus, mammilary body, and parietal region. There was an ill-defined soft tissue in the right temporal region adjacent to the sphenoid sinus assoc with narrowing of the distal cavernous and supraclinoid segment of right ICA . Pansinusitis. Suggested contrast to r/o cerebral abscess.
MRI BRAIN – FLAIR- INFARCT INVOLVING TEMPORAL LOBE
MRI BRAIN WITH MRA- DWI- ACUTE INFARCT
MRI BRAIN – T2WI
And now, turning our case towards “infarcts”, giving a spark would be because of paroyxsmal atrial fibrillation, creating an embolic infarct! So started on anticoagulants and antiplatelet after consulting with neuro team and waiting for a change to happen.
As the case required further work, CT BRAIN with contrast was taken after getting clearance from the Nephro team. CT brain with contrast showed the following:
CT brain with contrast: Acute infarct in the right gangliocapsular region. cavernous sinus thrombosis. pansinusitis. Right temporal lobe abscess with extension into right orbit.
CAVERNOUS SINUS THROMBOSISPANSINUSITIS :
In order to probe into the definitive cause, the case was discussed with ENT team and planned for endoscopy. It was planned for surgical debridement also.
Diagnostic nasal endoscopy and biopsy: Black necrotic material++ (thick eschar) was noted involving the inferior and middle turbinate. Extensive disease was noted involving the bilateral ethmoids. Multiple tissues were taken and sent for fungal culture and biopsy.
Black necrotic thick eschar, biopsy is taken
Extensive disease involving inferior and middle turbinate
Culture growth of mucormycosis in sabouraud dextrose agar
Day 1 24 hours growth
40-hours growth with 48 hours AT 25 Degree Celsius
Microscopic view
Microscopic view of rhizopus oryzae–showing hyphae with spores in 40xfocus
View in 100x focus Rhizopus species
The patient was finally diagnosed with rhinocerebral mucormycosis, first case in our hospital. The patient continued to deteriorate and was eventually on inotropic support. Despite all aggressive measures, she succumbed to the disease.
A complex interaction of factors comprising 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 prominently being recognized in view of their impact on morbidity and mortality.
Mucormycosis is generally a group of uncommon infection caused by a fungus, but now it is becoming a common diagnosis in post-covid patients. Mucormycosis is an invasive fungal infection once called as zygomycosis, but the organisms that causes the infection, specific types of molds, have been scientifically reclassified, and the term mucormycosis came later. These infections are broken down into 5 presentations: rhinocerebellar, pulmonary, cutaneous, gastrointestinal, and disseminated.
The most common presentation is a sinus infection. In this case, the infection spreads outside the sinuses, causing necrosis of the roof of the mouth, involving 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 the eyes, there can be swelling, proptosis, vision loss, and potential 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.
This is a case of unusual presentation of rapidly developing a fungal infection in a patient with pre-existing co-morbidities in the background of COVID-19.
Increase in mucormycosis in the Indian context appears to be an intersection of diabetes (high prevelance), rampant use of corticosteroids (increases the blood sugar level and opportunistic fungal infections), COVID-19 (lymphopenia, endothelial damage, cytokine storm), and contaminated oxygen equipment.
Dr. Niveda R Resident 1st Year – Dept. of Emergency Medicine Kauvery Hospital Chennai
