Primary cutaneous mucormycosis of the abdomen at the site of repeated insulin injections

Abstract

A 71-year-old woman with metastatic squamous cell carcinoma of the lung and insulin-dependent type 2 diabetes mellitus presented with a necrotic lesion on her lower abdomen. Further history revealed that this was the site of repeat insulin injections with reuse of the same needles. On investigation, biopsy of the site was positive for broad, aseptate, right-angle branching fungal hyphae consistent with mucormycosis. Studies have shown that insulin needle reuse is a common practice among diabetics for several reasons, including cost and convenience. While the current American Diabetes Association guidelines suggest that this is an acceptable practice among the general population of diabetics, they advise against it in patients who are actively ill or immunocompromised. Discussion about insulin needle reuse should be of utmost importance among providers and their diabetic patients, especially for patients who are immunocompromised.

Management of Infectious Emergencies for the Inpatient Dermatologist

“…Infection has been reported at sites of insulin injection, intravenous catheters, and spider bites [52,53]. Secondary cutaneous mucormycosis is due to dissemination from another infected location, commonly rhino-orbital-cerebral [54].…”

“…Primary cutaneous mucormycosis lesions can present anywhere on the body but are most commonly seen on the extremities [52]. The lesions initially present as reddish-purple, indurated plaques that progress to necrotic, ulcerating lesions with an erythematous halo [54,56]. Mucormycosis may involve fascia, muscle, and bone and can cause blood-borne disseminated disease [54, 57•].…”

“…Secondary cutaneous mucormycosis is more common than the primary infection and occurs due to rhino-orbital-cerebral infection [56]. Patients present with acute sinusitis with unilateral periorbital edema, fever, purulent or bloody nasal discharge, headache, and necrotic eschar [54,56]. The black eschar can be seen in the nasal mucosa, palate, or periorbital skin [54].…”

“…Patients present with acute sinusitis with unilateral periorbital edema, fever, purulent or bloody nasal discharge, headache, and necrotic eschar [54,56]. The black eschar can be seen in the nasal mucosa, palate, or periorbital skin [54]. Once the palate is involved, the fungus has osteolytic activity and can destroy facial bones [59].…”

“…Prompt diagnosis can prevent sequelae such as angioinvasion, disfiguring surgery, and loss of critical tissue [60]. The differential diagnosis includes candida infection, aspergillosis, gangrene secondary to bacterial infection, and pyoderma gangrenosum [54,56,61]. Biopsy at the center of the lesion with histopathology and fungal culture can aid in the diagnosis.…”