Case Example

A 51-year-old woman was transferred from a small community emergency department for subspecialty evaluation. The patient had presented to that facility the previous night complaining of headache and fever for three days with a sudden loss of vision in her left eye. During our evaluation, the patient reported that one week earlier, she fell, striking the left side of her face and sustaining several small abrasions. She denied other facial trauma. Further history revealed a general malaise and gradual weight loss for about one month's duration. She also admitted to falling occasionally in the past. Her past medical history included non-insulin-dependent diabetes mellitus for "several years." She was non-compliant with her oral hypoglycemic medication. She denied other past medical history.

The patient was noted to have a blood pressure of 164/86 mmHg, a pulse rate of 82 beats/min, a respiratory rate of 18 breaths/min, and a rectal temperature of 99.6°F. Fingerstick glucose was 284 mg/dL. The patient was alert and oriented, although somewhat apprehensive. Her left eye was proptotic; her sclera were muddy bilaterally. Marked chemosis was noted on the left. The left periorbital area was swollen and erythematous with abrasions sustained with her recent fall. The left eye had no light perception, with the pupil midpoint and fixed. The left-sided extraocular muscles were paralyzed. The right eye exam and extraocular muscles were normal. There was a 4 cm black necrotic area on the left hard palate. The neck exam was normal. Examination of the chest was without abnormalities. The abdomen was benign. The extremities were normal except for dry, flaking skin.

Screening serum chemistries showed a sodium level of 132 mEq/L, potassium of 3.1 mEq/L, chloride of 95 mEq/L, and bicarbonate of 18 mmol/L, resulting in an anion gap of 21 mmol/L. Serum glucose was 272 mg/dL and liver function panel was normal except for a lactate dehydrogenase of 307 U/L. Screening coagulation studies were normal. Serum acetone was markedly positive. Complete blood count (CBC) revealed a white cell count of 12,800/mm3 with a leftward shift. The rest of the CBC findings were within normal range. The electrocardiogram and chest X ray were normal.

In consideration of the patient's history of diabetes, the positive serum acetone, the low serum bicarbonate, and the high anion gap, the diagnosis of diabetic ketoacidosis (DKA) was made. Therefore, the patient was treated with intravenous insulin and normal saline. It was believed that she also had an infection of the soft tissues of the left orbit; infection and paralysis of the third nerve by a retro-orbital abscess could explain the unilateral blindness and proptosis.

This was confirmed by contrast-enhanced computed tomography (CT) of the head, orbits, and paranasal sinuses. The CT showed no intracranial abnormalities. No midline shift was present. There were no signs of intracranial abscess or infection. There was an air fluid level present in the left maxillary sinus, without evidence of bone destruction. Fluid and mucosal thickening were noted in the left ethmoid and frontal sinuses with no evidence of bone destruction. An air fluid level was present in the left sphenoid sinus. The CT scan further revealed left periorbital soft-tissue swelling. The left retrobulbar fat appeared infiltrated and "dirty." The left extraocular muscles were swollen. These changes suggested orbital cellulitis. No discrete abscess collection was seen. The left eye was proptotic. On one CT image, the left superior ophthalmic vein was prominent, suggesting thrombosis. The cavernous sinus appeared normal and there was a loss of fat planes in the left masticator space, suggesting infection.

Because of her immunocompromised state, her presentation with DKA, the CT findings of retrobulbar infiltration, and the necrotic areas in the mouth, the diagnosis of mucormycosis with possible retrobulbar abscess was suspected. Urgent otolaryngology and ophthalmology consultations were obtained. A biopsy of the left palate lesion was obtained (Fig. 1).

FIGURE 1 Mucormycosis fungal elements with broad and branching nonseptated hyphae. The consulting services concurred with the diagnosis, and the patient urgently went for surgical debridement. Surgical specimens of the left sinus system and the hard palate lesion tested positive for mucormycosis. The patient later underwent serial debridements, enucleation of the left eye, drainage of the retrobulbar abscess, and aggressive intravenous antifungal treatment. The patient did well after her debridements and antifungal treatment and survived to discharge one month later. Source. (Photo) Courtesy of Dr. Marco A. Ayala, LT and Dr. Gretchen S. Folk, LCDR, DC, USNR, Naval Medical Center San Diego, CA, U.S.A.

FIGURE 1 Mucormycosis fungal elements with broad and branching nonseptated hyphae. The consulting services concurred with the diagnosis, and the patient urgently went for surgical debridement. Surgical specimens of the left sinus system and the hard palate lesion tested positive for mucormycosis. The patient later underwent serial debridements, enucleation of the left eye, drainage of the retrobulbar abscess, and aggressive intravenous antifungal treatment. The patient did well after her debridements and antifungal treatment and survived to discharge one month later. Source. (Photo) Courtesy of Dr. Marco A. Ayala, LT and Dr. Gretchen S. Folk, LCDR, DC, USNR, Naval Medical Center San Diego, CA, U.S.A.

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