(542) A Black Cloud as Pungent as Truffle Mushrooms: A Case Report of Probable Rhinocerebral Mucormycosis

Introduction: Mucormycosis, aka black fungus, is found in soil or decaying vegetation. Occasionally, this fungus is found in immunocompromised hosts and diabetics. Globally, it has a rare incidence of .005 to 1.7 per million, yet a mortality rate of 25-62% in those specifically with rhino-cerebral mucormycosis associated with DM.

Description: A 67 y/o male with a medical history of uncontrolled DMII, urinary retention, hypertension and a newly identified nasopharyngeal mass presented to the ED with altered mental status and hyperglycemia - objectively in diabetic ketoacidosis (DKA). The patient had complained of left ear pain and headaches weeks prior. He arrived hypotensive, tachypneic with a GCS of 8 - requiring intubation, vasopressors and ICU admission. Labs revealed leukocytosis, lactic acidosis and acute renal failure. Imaging was unremarkable for acute findings on arrival, but further chart review revealed an infiltrative, erosive soft tissue mass within the left petro-occipital fissure with naso- and parapharyngeal invasion. He was empirically started on intravenous antibiotics with stress dose steroids. Infectious disease was consulted for concern of rhino-cerebral mucormycosis in the setting of septic shock, DKA and a newly identified erosive nasopharyngeal mass. Fungal cultures were obtained, he was then transitioned to liposomal amphotericin B. He improved drastically allowing cessation of pressors with resolution of DKA, lactic acidosis and a downtrending leukocytosis. Despite his hospital course being complicated by acute urinary retention and a urinary tract infection, he was able to be discharged after 6 days of amphotericin B and with a two-week course of posaconazole.

Discussion: Mucormycosis is rare, but its high mortality should lead providers to suspect it until proven otherwise. Amphotericin B is used as initial therapy, posaconazole or isavuconazole as step-down therapy and concomitant surgical debridement. A tissue biopsy with pathology and cultures is needed. In this case with an erosive nasopharyngeal mass, prior ear pain and DKA in septic shock, it was warranted to suspect and treat a diagnosis of mucormycosis. Keeping a high index of suspicion, with these risk factors and clinical presentation, is crucial to patient survival.