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Abstract:
KEY POINTS: Mucormycosis is almost exclusively an opportunistic infection that occurs in the setting of immunosuppression. Rapidly progressive or persistent infective symptoms despite broad-spectrum antibiotics in high-risk individuals should prompt investigation for invasive fungal infection such as mucormycosis. More than 1 infection may be present in a patient, particularly in those who are immunosuppressed. A 40-year-old Indigenous Australian woman was airlifted to hospital from a remote community. She had central chest pain, dyspnea, pedal edema and diabetic ketoacidosis, which she had developed after she stopped taking insulin because of her chest pain. Anxious to remain in her community, she had initially declined an earlier transfer but agreed 3 days later because her diabetic ketoacidosis was deteriorating despite additional insulin. Her medical history included type 1 diabetes, stage 1 chronic kidney disease, hypertension and asthma. She was on a basal–bolus insulin regimen, ramipril, amlodipine and amitriptyline. Her glycosylated hemoglobin at the time of admission was 10.3%. On examination, the patient was lethargic and tachypnoeic (respiratory rate 23 breaths per minute). She had signs of congestive cardiac failure, including raised jugular venous pressure, bibasal pulmonary crackles and pitting edema to her knees. Her heart sounds were normal. On investigation, her electrocardiogram showed new T-wave inversion in the inferolateral leads. She had a blood pH of 7.02 (reference range 7.35–7.45) with high anion gap, plasma glucose 38 (reference range 4.0–7.8) mmol/L, plasma ketones 7.6 (normal < 0.6) mmol/L, high-sensitivity troponin elevation from 199 to 264 (normal < 13) ng/L, hypophosphatemia 0.30 (reference range 0.75–1.50) mmol/L, hyponatremia 120 (reference range 135–145) mmol/L, serum potassium 4.8 (reference range 3.5–4.5) mmol/L and serum creatinine 175 (reference range 60–110) μmol/L. She had neutrophilia of 13 (reference range 2.0–7.5) ×109/L. Her C-reactive protein was 28.5 (normal < 5.0) mg/L. HIV serology was negative. A chest radiograph showed peribronchial cuffing with no focal consolidation. A transthoracic echocardiogram revealed moderate left ventricular hypertrophy. We thought that her diabetic ketoacidosis had been precipitated by an acute myocardial infarction. The patient declined to undergo a cardiac angiogram. Within 24 hours, her diabetic ketoacidosis had resolved with fluid and insulin infusion. On the third day of admission, she reported bloody sputum, sharp right-sided chest pain and painful swallowing. Chest computed tomography (CT) showed a 2.2 × 2.0-cm right lower-lobe cavitary mass (Figure 1). Sputum microscopy showed pauci-septated filamentous fungi, which subsequently grew Rhizopus microsporus, a Mucorales species (Figure 2). The minimum inhibitory concentrations for amphotericin B and posaconazole were 0.5 mg/L and 1 mg/L, respectively.
