A Patient with Newly Diagnosed Diabetes Presenting with Sino-Orbital Mucormycosis

ABSTRACT Objective: To present the case of a patient who developed sino-orbital mucormycosis after an occupational exposure and was found to have newly diagnosed uncontrolled diabetes. Methods: We present the patient's clinical, laboratory, imaging, and histopathology findings and review literature relevant for the evaluation and management of patients with diabetes and suspected mucormycosis. Results: A 53-year-old man with a past medical history of mild-intermittent asthma presented with nasal congestion for 1 month and left-eye pain, swelling, and double vision for 3 days. Patient was employed as a construction worker and reported working on water-damaged houses, pulling out rotten wood and wet plasterboard after Hurricane Sandy. Examination revealed left-eye proptosis, erythema of the superior lid, and diplopia upon upward and right lateral gaze. The left nasal cavity contained mucopurulent discharge. Laboratory analyses were significant for blood glucose of 450 mg/dL with a hemoglobin A1c of 12.2%. Admission computed tomography (CT) demonstrated aggressive pansinusitis with invasion of the left orbit. Vancomycin, piperacillin/tazobactam and posaconazole were administered in addition to intravenous dexamethasone and insulin. Initial functional endoscopic sinus surgery (FESS) with extensive debridement was performed with negative cultures and histopathology. Repeat CT revealed new orbital abscess formation. A second FESS was performed, and histopathology findings were compatible with angioinvasive mucormycosis. Liposomal amphotericin B was administered, with clinical improvement and radiographic stabilization of lesions. Conclusion: A patient with uncontrolled diabetes and history of prolonged exposure to decaying organic matter and/or construction activity who presents with severe sinoorbital infection not responding to antibiotics is at a high risk of having mucormycosis. Prompt treatment with systemic antifungals and surgical debridement is critical for survival and should be initiated based on clinical suspicion. Further investigation is needed to clarify the association between mucormycosis and professional/environmental exposure to spores of the fungus. Abbreviations: CT = computed tomography DKA = diabetic ketoacidosis LAmB = liposomal amphotericin B MRI = magnetic resonance imaging