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Diabetic ketoacidosis and coronavirus disease 2019-associated mucormycosis: a case report
Vanessa Monroig1, Keiko M Tarquinio2,3
1Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA. vmonroi@emory.edu.
Background:
Mucormycosis is a rare, life-threatening fungal infection that affects immunocompromised hosts. Diabetes mellitus is a common predisposing condition and most often presents with rhino-orbital-cerebral infection. Association with coronavirus disease 2019 infection was revealed following a resurgence in cases of mucormycosis during the second wave of the pandemic wherein poorly controlled diabetes mellitus was the most significant risk factor in the affected population. Rhino-orbital-cerebral mucormycosis has a high mortality rate, and cerebral involvement is a poor prognostic factor. Herein, we report a case of newly diagnosed diabetes mellitus with concurrent coronavirus disease 2019 infection complicated by diabetic ketoacidosis and rhinocerebral mucormycosis at presentation, describe the diagnostic and therapeutic challenges, and discuss the interventions that ultimately resulted in a favorable clinical response.
Case Presentation:
We describe the case of a previously healthy 13-year-old African American female patient with newly diagnosed diabetes mellitus and concurrent severe acute respiratory syndrome coronavirus 2 infection whose disease course was complicated by rhinocerebral mucormycosis. She presented with fever, altered mental status, and Kussmaul respirations and was diagnosed with diabetic ketoacidosis with concern for cerebral edema. Concern for infectious cerebritis arose due to recurring fevers and persistently altered mental status despite correction of her metabolic derangements. This raised concern for infectious cerebritis and prompted evaluation with serial head imaging, lumbar puncture, and initiation of broad empiric antimicrobial regimen. Head imaging revealed an evolving cerebral abscess, and fungal deoxyribonucleic acid was identified on blood metagenomics testing, which ultimately confirmed the diagnosis of rhinocerebral mucormycosis. Treatment was challenging as she required surgical debridement of the frontal lobe and aggressive antifungal therapy complicated by electrolyte derangements and electrocardiogram changes that necessitated modification of the antimicrobial regimen. Despite these challenges and high mortality rate, the patient was discharged from the hospital in stable condition to inpatient rehabilitation service for reconditioning after prolonged hospitalization.
Conclusion:
Rhinocerebral mucormycosis mortality is associated with delays in therapeutic interventions, thus a high index of suspicion and early recognition were essential for timely initiation of antifungal therapy and surgical debridement.
Insights
A rare fungal infection, mucormycosis, complicated a young patient
Area of Science:
- Infectious Diseases: Focus on opportunistic fungal infections in immunocompromised individuals.
- Endocrinology: Exploring the link between diabetes mellitus and severe infections.
- Critical Care Medicine: Management of complex cases involving co-infections and multi-organ involvement.
Background:
- Mucormycosis is a life-threatening fungal infection primarily affecting immunocompromised individuals, with diabetes mellitus being a significant risk factor.
- A resurgence of mucormycosis cases, particularly rhino-orbital-cerebral infections, was observed during the COVID-19 pandemic, linked to poorly controlled diabetes.
- Cerebral involvement in rhino-orbital-cerebral mucormycosis indicates a poor prognosis and high mortality rate.
Observation:
- A previously healthy 13-year-old female presented with newly diagnosed diabetes mellitus, diabetic ketoacidosis, and concurrent COVID-19 infection.
- The patient exhibited symptoms of fever, altered mental status, and respiratory distress, raising concern for infectious cerebritis and cerebral edema.
- Diagnostic workup, including serial head imaging and blood metagenomics, confirmed rhinocerebral mucormycosis with an evolving cerebral abscess.
Findings:
- The case highlights the diagnostic challenges in identifying rhinocerebral mucormycosis co-occurring with diabetic ketoacidosis and COVID-19.
- Treatment involved aggressive antifungal therapy and surgical debridement of a frontal lobe abscess, complicated by electrolyte imbalances and cardiac issues.
- Despite the complexities and high mortality associated with cerebral mucormycosis, the patient achieved a favorable clinical outcome with prolonged hospitalization and rehabilitation.
Implications:
- Early recognition and a high index of suspicion are crucial for timely diagnosis and intervention in cases of suspected mucormycosis.
- Prompt initiation of antifungal therapy and surgical debridement can significantly improve outcomes in patients with rhinocerebral mucormycosis.
- This case underscores the critical interplay between diabetes mellitus, COVID-19, and opportunistic fungal infections, emphasizing the need for vigilant patient monitoring.
