Case report Page 1 of 4 Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY) For citation purposes: Sangwan J, Juyal D, Negi V, Singh M, Sharma N. Rhinocerebral mucormycosis with therapeutic challenges encountered in a rural resource constrained setting. OA Case Reports 2013 Jul 12;2(6):54. Compeing interests: none declared. Conlict of interests: none declared. All authors contributed to the concepion, design, and preparaion of the manuscript, as well as read and approved the inal manuscript. All authors abide by the Associaion for Medical Ethics (AME) ethical rules of disclosure. Rhinocerebral mucormycosis with therapeutic challenges encountered in a rural resource constrained setting J Sangwan 1 *, D Juyal 1 , V Negi 1 , M Singh 2 , N Sharma 1 Conclusion Rhinocerebral mucormycosis is an acute opportunistic fungal infection, which follows an invariably fulmi- nant course in diabetic patients. A rhinosinusal symptomatology in a patient with diabetic ketoacidosis should raise a high index of suspicion for possible rhinocerebral or rhi- nomaxillary mucormycosis. Introduction Mucormycosis is an opportunistic and frequently fulminating fungal infec- tion caused by members of the fam- ily Mucoraceae, order Mucorales and class Zygomycetes 1 . Common genera involved are Rhizopus, Mucor and Absidia which are ubiquitous fungi surviving on decaying vegetation and diverse organic matter. The major predisposing factors for acquisition of mucormycosis are uncontrolled dia- betes mellitus (DM), metabolic acido- sis, haematological malignancies and immunosuppression 2,3 . Depending on the patient’s immunological status disease may manifest as rhinocere- bral, pulmonary, cutaneous, gastroin- testinal or haematogenous form 4 . Rhinocerebral mucormycosis (RCM) is the most serious, rapidly progres- sive, fatal form of the disease with a mortality rate of 70%–100% if not treated adequately 5,6 and most com- monly manifests itself in the setting of poorly controlled DM especially with ketoacidosis (KA). Rapid progression and high mortality necessitate prompt recognition and aggressive treatment to increase survival rate. We present a case of rapidly pro- gressive RCM in a 17-year-old girl with ketoacidotic type 1 DM. The case exemplifies the therapeutic challenges encountered in a rural resource constrained setting. Case report A 17-year-old girl was brought to the emergency department of our hospi- tal with the complaint of breathing difficulty for the last three days. The patient’s medical history included type 1 DM, with poor drug compli- ance. Her parents gave a history of odontalgia which she developed after using a match stick as a tooth pick. She took prescription from Vaidh (unauthorised medical practitioner in the village) and used clove oil and some local herbs for the treatment. After two to three days she devel- oped low-grade fever, lethargy, puru- lent blood tinge nasal discharge from the left nostril. On admission, she was febrile (39.1°C), had facial puffiness, marked left-sided hemifacial oedema, perior- bital oedema, unilateral mucopuru- lent rhinorrhea, had acidotic breath and difficulty in breathing. On physi- cal examination, the nasal wall and the upper lip showed necrotic lesions (more so) on the left side (Figure 1), also necrotic mucosal lesions in the Abstract Introduction Rhinocerebral mucormycosis is the most serious, rapidly progres- sive, fatal form of the disease with a mortality rate of 70%–100% if not treated adequately and most com- monly manifests itself in the setting of poorly controlled diabetes mel- litus especially with ketoacidosis. Rapid progression and high mortal- ity necessitate prompt recognition and aggressive treatment to increase survival rate. We present a case of rapidly pro- gressive rhinocerebral mucormycosis in a 17-year-old girl with ketoaci- dotic type 1 diabetes mellitus. The case exemplifies the therapeutic challenges encountered in a rural resource constrained setting. Case report A 17-year-old girl was brought to the emergency department of our hospi- tal with the complaint of breathing difficulty for the last three days. On admission she was febrile (39.1°C), had facial puffiness, marked left- sided hemifacial oedema, periorbital oedema, unilateral mucopurulent rhinorrhea, had acidotic breath and difficulty in breathing. On physi- cal examination, nasal wall and the upper lip showed necrotic lesions (more so) on the left side, also necrotic mucosal lesions in the oral and nasal cavity were evident. *Corresponding author Email: jyolathwal@yahoo.co.in 1 Department of Microbiology & Immunology, Veer Chandra Singh Garhwali Governmental Medical Science and Research Institute, Uttarakhand, India 2 Department of Medicine, Veer Chandra Singh Garhwali Government Medical Science and Research Institute, Uttakhand, India Infectious Diseases Figure 1: Patient’s picture showing marked hemifacial and periorbital oedema on the left side (note the presence of black necrotised nasal wall and upper lip).