Fulminant Auricular Mucormycosis in a Diabetic Patient

Abstract

Human mucormycosis is an atypical fungal infection that commonly affects the skin, but rarely the auricular region. A 32-year-old diabetic woman, agricultural worker, was admitted with swelling, redness and mild signs of epidermolysis of the left ear, associated with intense pain, facial paralysis and septic signs. The ear cellulitis evolved into necrosis of the same region on the following day. Surgical debridement was performed and antimycotic therapy was started with poor response. The patient died in 48h. Culture was confirmatory for Rhizopus sp. Keywords: Mucormycosis; fungal infections; diabetes; RhizopusMucormycosis is a rare but aggressive fungal infection, which occurs most often among patients with diabetes mellitus and other immunosuppressed individuals 1 . Most cases are associated to Rhizopus sp, a genus of common saprophytic fungi on plants and decaying organic matter. Most human infections are rhinocerebral and sinopulmonary. Cutaneous mucormycosis are also frequent and generally result from direct inoculation of fungal spores in the skin through any kind of injury, causing tissue necrosis by angioinvasion. The authors reported a case of a 32-year-old diabetic woman, agricultural worker, admitted to this service with a fulminant auricular mucormycosis. CASE REPORTA 32-year-old female patient from the public health system, with type 1 diabetes not adequately managed, was admitted to the author's service with pain on the left ear and tachypnea for 2 to 3 days. She reported a story of periauricular wounds about two days after the onset of the symptoms. She was an agricultural worker in the tobacco industry, and had been engaged in cleaning tobacco leaf stitching machines in the previous days. On clinical examination, a peripheral ipsilateral facial palsy was present. There was swelling, redness and mild signs of epidermolysis of the left ear, associated with intense pain, respiratory frequency of 25bpm and heart rate of 105 bpm. There was no fever. A significant ear canal edema made it impossible to perform a satisfactory otoscopy. The serum glucose level on arrival was 350 mg/dL. The first clinical hypothesis was a malignant external otitis caused by Herpes Zoster or bacterial infection. A 24-hour scheme of intravenous acyclovir and antibiotics was introduced. Clinical management for decompensated diabetes was also performed. In 24 hours, the patient got worse. Fever was present. The left auricular region started to show necrotic signs and she required intensive care for respiratory and hemodynamic support. The cranial CT showed no signs of fasciitis, mastoiditis or damage to the central nervous system. In few hours, the necrotic area of the ear became larger (Figure 1) and an urgent extensive debridement was performed, including ear amputation and resection of peripheral soft tissues. During the surgical procedure, there were signs of arterial and venous thrombosis and extensive gangrene of tissues, without purulent secretion. Mucormycosis was suspected and liposomal amphotericin B was intr...

A Case Report of Complete Resolution of Auricular Mucormycosis in an 18-Month-Old Diabetic Child

“…This is the first case of mucormycosis of a child that completely resolved with marked improvements of the facial palsy. Furthermore, the rest of the papers reporting mucormycosis in adults were mostly immunocompromised with diabetes and a high mortality rate regardless of proceeding to surgery or not [ 2 , 3 , 11 , 14 ]. Nonetheless, all cases used a single therapy of amphotericin B, while we started a multidimensional therapy on the hypothesis of availability of a secondary infection due to the rapid progressiveness of the necrosis.…”

“…Mucormycosis is a type of fungal infection, which occurs mostly in diabetic patients, belonging to the order Mucorales [ 1 ]. It is the immunocompromised status of diabetic individuals that makes them more susceptible to such an aggressive infection as they can be prone to impaired phagocytic function which may occur during the ketoacidosis state [ 1 , 2 ]. The fungal spore's inoculation that deposit in the cutaneous part of the body is hypothesized to be often occurring from the result of injury, while some report it as an air-borne type of transmission pathogen [ 2 , 3 ].…”