Tariq Ghafoor, Amer Majeed, Sher Muhammad, Shahid Mahmud, Arshad Mahmood.
Rhinocerebral Mucormycosis.
J Pak Med Assoc Jan ;54(12):632-4.

A ten years old girl was admitted with the complaint of breathing difficulty for last 3 days. There was no significant past history. Her birth, developmental and family history were unremarkable. On examination her anthropometric data was below the 3rd centile for age. She had acidotic breathing, tachycardia and normal temperature and blood pressure. Systemic examination was normal except few crepitations on chest auscultation. Investigations showed raised blood glucose (591mg/dl = 32.8 mmol/L), increased total leukocyte count (20.7x10e9/L). She had mild renal impairment with serum creatinine 1.66mg/dl (147 umol/L), serum sodium 136 mmol/L, serum potassium 4.4 mmol/L. Urine examination was positive for ketone bodies and serum bicarbonate level was decreased to l5mmol/L. Considering the clinical picture and investigations, a diagnosis of diabetic ketoacidosis (DKA) was made and her management was started. With conservative management of renal impairment, intensive insulin therapy and antibiotics her general condition gradually improved and she became conscious and orientated on 6th day of hospitalisation. Within the next two days she developed yellow coloured discharge from left eye along with proptosis, restricted ocular movements and deterioration of vision. Immediate consultation of ophthalmologist was asked, who made a diagnosis of left 3rd nerve palsy with central retinal artery occlusion most probably due to orbital cellulitis. She had mucoid discharge from the nose and examination by otolaryngologist documented a black membrane sticking to middle portion of the nasal septum and black slough over the left side of hard palate. These findings were suggestive of fungal sinusitis. The CT scan showed a mass in left ethmoidal sinus extending into retrobulbar area of left eye. External ethmoidectomy and surgical debridement for orbital decompression was performed on 12th day of hospitalization. Amphotericin B infusion at 1mg/kg (20 mg) daily was started along with broad spectrum antibiotics. The biopsy specimen was sent for histopathology and culture. The culture yielded the growth of mucor species.

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