Journal of Medicine Vol 4 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
CASE REPORT
Rhinocerebral Mucormycosis in a
Patient with Diabetic Nephropathy
A. Mathew , J.C. Varghese, P. Nair *, V.N. Unni
ABSTRACT
Diabetes Mellitus and immunosuppressed states predispose patients to fungal infections like mucormycosis: We report
a case of rhino cerebral mucormycosis in a patient with diabetic nephropathy and moderate renal failure.
Key words : Rhinocerebral Mucormycosis, Diabetic Nephropathy
INTRODUCTION
Rhinocerebral mucormycosis is a
life threatening infection that is associated
with immunosuppressed states.
The disease usually spreads rapidly;
rarely, it may pursue an indolent
course 1 . In diabetic subjects, it is characteristically
associated with diabetic
ketoacidosis. This case report describes
fulminant and progressive rhinocerebral
mucormycosis in a subject with
diabetic nephropathy (without
ketoacisosis). In addition to the case
report, a brief discussion with the relevant
review of the literature is also
presented.
CASE REPORT
A 45 years old manual labourer, a
known diabetic since 15 years and
hypertensive since six years, was admitted
to our hospital with pain and
progressive swelling of the left side
of the face since one week. He was
found to have very high blood sugar
levels and moderate renal failure, and
was referred to the Nephrologist for
further treatment.
Dept. of Nephrology, * Dept. of Otorhinolaryngology,
AIMS, Kochi.
On admission he was febrile, conscious
and oriented. BP was 160/100
mmHg. He had erythema and oedema
over the left malar region of the face.
Evaluation by ENT surgeon showed
features of left maxillary sinusitis with
sloughing of nasal mucosa. Optic
fundi revealed non-proliferative diabetic
retinopathy.
Investigations showed neutrophilic
leucocytosis (21,000/cu.mm) with
shift to the left and prominent toxic
granules in neutrophils. Blood sugars
were uncontrolled (FBS: 523mg/dl,
PPBS: 698 mg/dl); he had proteinuria
(1800 mg in 24 hours) and a moderate
renal failure (S.Creatinine: 3.3mg/
dl). Ultrasonogram showed normal
sized kidneys with increased
echogenicity. Roentgenogram of
paranasal sinuses showed haziness of
the left maxillary sinus. CT Scan of
the paranasal sinuses showed soft tissue
density occupying the left
maxillary antrum and extending into
the middle meatus with occlusion of
the left osteomeatal complex (Fig.1).
There was also extensive involvement
of the anterior ethmoidal sinuses. He
was started on antibiotics (Augmentin
and Ofloxacin) as well as
antihypertensives and blood sugars
were controlled with Insulin
Fig.1: CT Scan of the paranasal sinuses
showing soft tissue density
occupying the left maxillary antrum
and extending into the middle meatus
with occlusion of the left osteomeatal
complex.
When he was initially seen by ENT
surgeons he had only signs of left maxillary
sinusitis. Within 36 hours, he
developed an oroantral fistula on the
left side along with sinus formation
in the left lacrymal sac region (Fig.2).
He was taken up for a Cald -Well Luc
Surgery and left ethmoidectomy. Left
maxillary antrum contained pus and
sloughed mucosa and vascularity was
impaired. Sloughed middle turbinate
was excised and extensive debridement
was done; specimens were sent
for bacterial and fungal cultures and
histopathology.
Histopathological examination of
the sloughed nasal mucosa revealed
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