Presumed Rhino-Orbital Mucormycosis

A patient with a past medical history of PCOS and type 2 diabetes mellitus presented to an outside hospital six weeks pregnant with right sided facial pain and periorbital swelling. Ophthalmology was consulted for sudden, progressive vision loss in the right eye. Her exam was notable for visual acuity of NLP in the right eye and 20/20 in the left eye. Intraocular pressures were 13 and 15. Additionally, the patient had notable proptosis of the right eye and restrictions in all directions of gaze. Anterior segment exam at bedside revealed an otherwise white and quiet eye, and a normal fellow anterior eye exam. On posterior segment exam, the right eye was found to have retinal whitening of the macula and inferior periphery, and significant optic nerve edema. On initial workup, the patient's hemoglobin A1c was revealed to be 14.1 and her initial blood glucose was in the 400s. The patient’s neuroimaging revealed enhancement and mucosal thickening in the right maxillary and ethmoid sinuses with extension into the orbital apex and associated perineuritis of the optic nerve. There was no associated intracranial spread noted. Pathology revealed fungal elements which were negative for aspergillus immunohistochemistry, but not diagnostic for fungal speciation. Given the clinical picture and pathology she was treated as presumed rhino-orbital mucormycosis. Treatment was initiated with systemic amphotericin B, systemic antibiotics, three retrobulbar amphotericin B injections, and several sinus debridements with the otolaryngology service. During her hospital course, her underlying metabolic abnormality was corrected, and although she unfortunately suffered an early term pregnancy loss early in the hospital course, she stabilized. Given the patient’s clinical improvement, exenteration was deferred despite no improvement in her motility or visual acuity, and the patient was discharged on systemic posoconazole.

Presentation Date: 09/21/2023

Issue Date: 10/06/2023