Pulmonary Mucormycosis Without Rhinocerebral Involvement: A Case Report

Mucormycosis is an opportunistic fungal infection that commonly occurs in patients with predisposing conditions, such as poorly controlled diabetes mellitus and immunocompromised states. In patients with diabetes, rhinocerebral disease is more commonly described, whereas isolated pulmonary mucormycosis (PM) is less typical and is more often associated with profound immunocompromise. The presentation in this case was further notable for occurring in the setting of a hyperosmolar hyperglycemic state (HHS) rather than diabetic ketoacidosis (DKA), without rhinocerebral involvement. We present the case of a 53-year-old man with type 2 diabetes mellitus treated with insulin who initially presented with cough, fatigue, and generalized malaise and re-presented five days later after a syncopal ground-level fall with right shoulder pain and persistent weakness. He was found to have a HHS and sepsis secondary to pneumonia, with sputum and bronchoalveolar lavage cultures growing Enterobacter cloacae complex. Imaging obtained during the evaluation of the shoulder injury revealed a nondisplaced proximal humeral fracture and an incidental large cavitary pulmonary lesion, prompting computed tomography of the chest, which demonstrated multiple cavitary consolidations and moderate-to-large bilateral pleural effusions. Bronchoscopy with biopsy demonstrated necrotic tissue containing broad, aseptate fungal hyphae morphologically consistent with mucormycosis. Computed tomography of the sinuses showed no evidence of rhinocerebral involvement. The patient was treated with meropenem and liposomal amphotericin B and was transferred to a tertiary-care facility for surgical evaluation and debridement. PM should be considered in patients with poorly controlled diabetes who develop pneumonia or cavitary disease, even in the absence of classic rhinocerebral involvement. This case underscores the need for prompt identification of PM, antifungal therapy, and early surgical intervention to improve outcomes.