Mucormycosis: More Than Meets the Eye!

A 42-year-old Hispanic man presented with a 3-day history of nausea and vomiting after being treated for 2 days with amoxicillin for a dental abscess. His past medical history included methamphetamine and tobacco use, hypertension, and uncontrolled type 2 diabetes mellitus (hemoglobin A1C of 13.4%). His initial vital signs were unremarkable. Physical examination was significant for right facial swelling. Laboratory tests were notable for serum glucose >400 mg/dL without diabetic ketoacidosis, leukocytosis (12.8 × 10 3 Venkatesh D. Dandagi S. Chandrappa P. et al. Mucormycosis in immunocompetent patient resulting in extensive maxillary sequestration. J Oral Maxillofac Pathol. 2018; 22: S112-S116 Google Scholar /uL), and an elevated C-reactive protein (11.7 mg/dL). On hospital day 2, he developed right-sided vision loss. Magnetic resonance imaging of the brain showed eye proptosis and ethmoid sinusitis. His affected teeth were extracted and the right maxillary sinus was drained. The sinus culture grew Candida. He was treated with fluconazole and intravenous vancomycin and cefepime. On hospital day 4, he developed facial paralysis and right central retinal artery occlusion with blindness. A repeat magnetic resonance imaging scan of the brain and magnetic resonance venogram showed severe right ethmoid, sphenoid, and maxillary sinusitis with cavernous sinus thrombosis. Intravenous heparin and steroids were started. On hospital day 9, he underwent drainage of the right maxillary sinus but developed orbital cellulitis and ophthalmoplegia of the right eye. Rush biopsies from the maxillary sinus were preliminarily interpreted as “invasive fungal elements” without further speciation. He was then transferred to our hospital for further care.