Case Presentation: A 22-year-old man with a history of sinusitis requiring surgery, presented with 3 weeks of right sided facial swelling and pain. He denied any facial trauma or drug use. He had used tap water for nasal rinses. The patient was diagnosed with sinusitis and treated with clindamycin and steroids but had progression of symptoms. On exam, he was afebrile and generally well appearing. He had restricted extraocular movements of the right eye. His right inferior eyelid and nasal sidewall were indurated and tender to palpation. He had bilateral nasal mucosa edema and purulence from the right middle meatus. Endoscopic sinus surgery was showed destruction of anatomical landmarks and biopsies demonstrated fungal invasion with mucormycetes. This prompted transfer to our hospital.After transfer, ophthalmology and otolaryngology performed multiple debridements. Systemic and intraocular amphotericin was administered with broadening of coverage to include posaconazole, micafungin, and isavuconazole after progression was noted. He underwent hyperbaric oxygen treatments in order to oxygenate ischemic tissues, augment phagocytic activity and reduce swelling. He received a dose of filgastrim based on previous literature.1 Despite these treatments the mucor progressed and subsequent MRIs demonstrated worsening involvement of the right cavernous sinus, both orbits, and the leptomeninges with progressive cerebritis involving his frontal lobe, meningitis, and extensive cerebral edema. The patient developed unrelenting headaches, nausea, vomiting, and had decreased levels of consciousness. After 75 days in our hospital, he was discharged to an inpatient hospice.
Discussion: This case illustrates the importance of considering invasive mucormycosis in the immunocompetent patient. Previously only patients with diabetes, suppressed immune systems, history of trauma or exposure to excessive iron were thought to be susceptible to infection with this otherwise indolent fungus, however there have been published series of cases of immunocompetent patients with invasive mucor. Up to 9.6% of all reported cases of mucormycosis take place in non-immunocompromised patients and 9.06% of patients with rhinocerebral mucormycosis have no predisposing factors. Consideration of invasive mucor in healthy patients with persistent sinusitis is key to prevent delayed diagnosis. Postponement in identification of invasive infection can also lead to possible treatment with steroids for allergic sinusitis which can exacerbate proliferation of the fungus. The cornerstone of treatment is aggressive source control with surgical debridement in conjunction with systemic and local injection of antifungals. More research as to why mucor affects patients without predisposing risk factors is needed as 20-58% of patients die of this infection.
Conclusions: It is essential to consider the diagnosis of invasive mucormycosis in the immunocompetent population to prevent the high morbidity and mortality of this disease.