Rhinocerebral mucormycosis with therapeutic challenges encountered in a rural resource constrained setting

Introduction Mucormycosis is an opportunistic and frequently fulminating fungal infection caused by members of the family Mucoraceae, order Mucorales and class Zygomycetes1. Common genera involved are Rhizopus, Mucor and Absidia which are ubiquitous fungi surviving on decaying vegetation and diverse organic matter. The major predisposing factors for acquisition of mucormycosis are uncontrolled diabetes mellitus (DM), metabolic acidosis, haematological malignancies and immunosuppression2,3. Depending on the patient’s immunological status disease may manifest as rhinocerebral, pulmonary, cutaneous, gastrointestinal or haematogenous form4. Rhinocerebral mucormycosis (RCM) is the most serious, rapidly progressive, fatal form of the disease with a mortality rate of 70%–100% if not treated adequately5,6 and most commonly manifests itself in the setting of poorly controlled DM especially with ketoacidosis (KA). Rapid progression and high mortality necessitate prompt recognition and aggressive treatment to increase survival rate. We present a case of rapidly progressive RCM in a 17-year-old girl with ketoacidotic type 1 DM. The case exemplifies the therapeutic challenges encountered in a rural resource constrained setting. Case report A 17-year-old girl was brought to the emergency department of our hospital with the complaint of breathing difficulty for the last three days. The patient’s medical history included type 1 DM, with poor drug compliance. Her parents gave a history of odontalgia which she developed after using a match stick as a tooth pick. She took prescription from Vaidh (unauthorised medical practitioner in the village) and used clove oil and some local herbs for the treatment. After two to three days she developed low-grade fever, lethargy, purulent blood tinge nasal discharge from the left nostril. On admission, she was febrile (39.1°C), had facial puffiness, marked left-sided hemifacial oedema, periorbital oedema, unilateral mucopurulent rhinorrhea, had acidotic breath and difficulty in breathing. On physical examination, the nasal wall and the upper lip showed necrotic lesions (more so) on the left side (Figure 1), also necrotic mucosal lesions in the Abstract Introduction Rhinocerebral mucormycosis is the most serious, rapidly progressive, fatal form of the disease with a mortality rate of 70%–100% if not treated adequately and most commonly manifests itself in the setting of poorly controlled diabetes mellitus especially with ketoacidosis. Rapid progression and high mortality necessitate prompt recognition and aggressive treatment to increase survival rate. We present a case of rapidly progressive rhinocerebral mucormycosis in a 17-year-old girl with ketoacidotic type 1 diabetes mellitus. The case exemplifies the therapeutic challenges encountered in a rural resource constrained setting. Case report A 17-year-old girl was brought to the emergency department of our hospital with the complaint of breathing difficulty for the last three days. On admission she was febrile (39.1°C), had facial puffiness, marked leftsided hemifacial oedema, periorbital oedema, unilateral mucopurulent rhinorrhea, had acidotic breath and difficulty in breathing. On physical examination, nasal wall and the upper lip showed necrotic lesions (more so) on the left side, also necrotic mucosal lesions in the oral and nasal cavity were evident.