It is not sweet inside! invasive rhino-orbital-cerebral mucormycosis as the initial presentation of diabetic ketoacidosis

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Mucormycosis is an aggressive, opportunistic fungal infection caused by organisms in the order Mucorales, including Rhizopus oryzae, the most common human pathogen. Uncontrolled diabetes mellitus (DM) and diabetic ketoacidosis (DKA) are the most common risk factors. Hyperglycemia and acidosis create an optimum milieu, particularly for Rhizopus species armed with a ketone-reductase system, to thrive by increasing the availability of iron, blunting the host immune response, and facilitating angioinvasion. Spores are ubiquitous in the environment, often inhaled via the nasal passages and spread via direct extension. There are several clinical forms with rhino-orbital-cerebral being the most common presentation. We report the case of a patient with covert invasive rhino-orbital-cerebral mucormycosis as the initial presentation of diabetic ketoacidosis. CASE PRESENTATION: A 46-year old male with no known prior medical history, initially presented with altered mental status and one week of flu-like illness. He was found to be in DKA; however, his mental status did not improve with standard DKA treatment. He developed right eye pain and proptosis was noted, which prompted an MRI. The results revealed bifrontal hemorrhagic cerebritis, pansinusitis, and right globe proptosis, concerning for invasive fungal sinusitis. LP was consistent with fungal infection. He was started on broad-spectrum antibiotics, as well as liposomal amphotericin B. The patient was emergently taken for endoscopic sinus surgery with debridement, followed by right orbitotomy with debridement. Frozen section demonstrated Mucorales and morphology consistent with the Rhizopus species. Treatment included a 2-week course of cefepime for sinusitis and a 6-week course of liposomal amphotericin B and oral posaconazole for mucormycosis, alongside tight glycemic control. Mental status initially improved, but subsequently declined. Repeat MRI/MRA showed acute left anterior cerebral artery infarction and progression of intracranial disease with development of frontal lobe abscesses. Unfortunately, the patient has had a prolonged hospitalization with minimal improvement in mental status. DISCUSSION: The patient had the most common clinical presentation of this rare disease. His undiagnosed and uncontrolled medical condition fostered the growth of a relatively innocuous organism to become an invasive and destructive entity resulting in severe morbidity. Management of DKA not only entails treatment of the accompanying metabolic derangements, but also a meticulous search for the underlying cause. In particular, being cognizant of occult infections facilitates early diagnosis and treatment. CONCLUSIONS: This case highlights the importance of an expeditious and comprehensive investigation to determine the etiology of DKA. Reference #1: Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis. 2012;54 (Suppl 1):S16-22. Reference #2: Rammaert B, Lanternier F, Zahar J, et al. Healthcare-associated mucormycosis. Clin Infect Dis. 2012;54 (Suppl 1):S44-S54. DISCLOSURES: No relevant relationships by Liwayway Andrade, source=Web Response No relevant relationships by Zachary Pinchover, source=Web Response No relevant relationships by Koonj Shah, source=Web Response No relevant relationships by Mohi Syed, source=Web Response