{"paper_id":"399fa4f9-00fd-404a-9afc-cda1282ef97b","body_text":"Fulminant Angioinvasive Pulmonary Rhizomucorosis in Diabetic Ketoacidosis: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fulminant Angioinvasive Pulmonary Rhizomucorosis in Diabetic Ketoacidosis: a case report Xinyu Li, Shaolong Shen, Xuedong Bai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8807863/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Infections by Rhizomucor species are aggressive invasive fungal diseases primarily affecting metabolically compromised hosts. Pulmonary involvement is diagnosticially challenging due to nonspecific clinical and radiological features, often leading to fatal delays. Case presentation We report a rapidly progressive case in a 30-year-old female with undiagnosed diabetic ketoacidosis (DKA). Initially mismanaged as community-acquired pneumonia due to misleading serological markers, the patient quickly developed type I respiratory failure. Diagnosis was confirmed via sputum culture and Chest computed tomography angiography (CTA), the latter revealing pathognomonic vascular involvement. Conclusion This case underscores the necessity of a high clinical suspicion for mucormycosis in DKA patients, emphasizing that early etiological identification and prompt antifungal therapy are critical for survival. Pulmonary mucormycosis Rhizomucor Diabetes Figures Figure 1 Figure 2 Background Mucormycosis is an invasive fungal infection caused by fungi of the order Mucorales(1). Clinically, it is classified into various forms based on the site of involvement, including rhino-orbital-cerebral, pulmonary, gastrointestinal, and cutaneous presentations(1,2). The disease predominantly affects immunocompromised individuals and often follows a rapidly progressive course(3,4). Patients with DKA represent a particularly high-risk group, as the associated hyperglycemia and metabolic acidosis create a conducive pathophysiological environment for fungal proliferation.(5) The diagnosis of pulmonary mucormycosis is particularly formidable, as its early clinical manifestations and radiological features frequently mimic those of severe bacterial pneumonia, leading to potential diagnostic ambiguity.This diagnostic ambiguity often leads to significant delays in initiating appropriate antifungal therapy. We present a case of rapidly progressive pulmonary mucormycosis in a young female with DKA, highlighting how its resemblance to common community-acquired pneumonia complicates early recognition. Case presentation A 30-year-old female farmer presented to the emergency department with an 8-day history of cough, sputum production, and fever, followed by one day of progressive dyspnea. She had a history of elevated blood glucose but had not received regular follow-up or glycemic control. Prior treatment at a local clinic with azithromycin and cephalosporins had been ineffective. On physical examination, the patient was tachycardic (140 bpm) and tachypneic (30 breaths/min). Auscultation revealed bilateral dry and moist crackles. Arterial blood gas analysis indicated severe metabolic acidosis with respiratory failure (pH 6.90, PaO₂ 95 mmHg, PaCO₂ 13 mmHg). Coagulation profiles showed a Prothrombin Time (PT) of 13.10 sec, Activated Partial Thromboplastin Time (APTT) of 37.30 sec, Fibrinogen (FIB) of 5.703 g/L, and D-Dimer of 0.87 µg/mL. Chest computed tomography (CT) demonstrated multiple patchy opacities in the bilateral perihilar regions (Fig. 1 ). CTA revealed absent opacification of the right upper lobe pulmonary artery and faint opacification of branches in the left upper lobe, right middle lobe, and bilateral lower lobes, suggestive of vascular involvement (Fig. 2 ). Additionally, cranial CT demonstrated multiple punctate hypodensities in the left watershed area, findings potentially associated with disseminated fungal infection. Magnetic resonance imaging (MRI) was not performed due to the patient's unstable clinical condition. Laboratory results confirmed community-acquired pneumonia, type I respiratory failure, and DKA. Emergent endotracheal intubation and mechanical ventilation were initiated. Pathogen testing revealed elevated Mycoplasma pneumoniae IgM (1.552 S/CO) and IgG (33.653 AU/ml), as well as influenza A IgM (8.195 S/CO). Initial empiric treatment included moxifloxacin, doxycycline, and oseltamivir. However, sputum culture subsequently grew Rhizomucor spp.. Consequently, doxycycline was discontinued (as Mycoplasma RNA was negative), and amphotericin B cholesterol sulfate complex (250 mg daily) was added to the regimen. Unfortunately, the patient’s condition was deemed too unstable for surgical debridement. Discussion This case highlights the catastrophic synergy between uncontrolled metabolic dysregulation and invasive fungal infection. While Mucorales are ubiquitous, invasive disease is rare and predominantly affects immunocompromised hosts(6). Diabetes mellitus is the most significant risk factor globally, associated with a mortality rate of up to 46%(5). In our patient, previously undiagnosed diabetes and severe ketoacidosis (HbA1c 14.3%) created a precipitating environment for Rhizomucor proliferation, confirming that metabolic status is a critical determinant of disease progression. The susceptibility of DKA patients to mucormycosis is mechanically distinct(7). Hyperglycemia and acidosis directly impair neutrophil chemotaxis and macrophage phagocytosis, the host's primary defenses against fungi(8). Furthermore, Mucor species thrive in acidic, glucose-rich environments and express ketone reductase, allowing them to flourish during ketoacidosis(9). This unique angioinvasive nature was clinically evident in our case through the rapid deterioration of respiratory function and the vascular involvement observed on CTA. The primary clinical challenge lies in the nonspecific presentation of pulmonary mucormycosis, which frequently mimics severe bacterial pneumonia or tuberculosis(10). In this case, the diagnosis was obscured by the patient’s initial presentation of fever and cough, alongside positive serology for Mycoplasma pneumoniae, leading to an initial focus on community-acquired pneumonia. This highlights a critical pitfall: in high-risk patients (e.g., those with DKA), co-infection or misleading serological markers should not preclude the investigation of invasive fungal disease when response to standard antibiotics is poor. Early recognition requires a multidisciplinary approach. While chest CT findings such as the \"vascular cut-off sign\" (as seen in our patient’s right upper lobe pulmonary artery) are highly suggestive of fungal angioinvasion, they are not pathognomonic. Therefore, definitive diagnosis relies heavily on obtaining deep respiratory specimens. Histopathological identification of broad, pauciseptate hyphae with right-angle branching remains the gold standard(10). Clinicians must maintain a high index of suspicion in diabetic patients presenting with pulmonary consolidation to initiate life-saving antifungal therapy and surgical evaluation without delay. Conclusion Conclusion Early symptoms of mucormycosis are often nonspecific. When patients with high-risk underlying conditions present with acute severe pulmonary infection, clinicians should maintain a high index of suspicion for mucormycosis. Diagnosis should be pursued through a multidisciplinary approach combining imaging and etiological studies for early confirmation. Treatment should be tailored based on individual patient factors, balancing antifungal therapy and surgical intervention to improve outcomes. Intravenous amphotericin B is the first-line treatment, while posaconazole or isavuconazole may be considered for patients intolerant to amphotericin B(11). Surgical debridement of infected tissue can improve prognosis, although it was not feasible in this case due to extensive pulmonary involvement. Abbreviations APTT Activated Partial Thromboplastin Time CT Computed tomography CTA Computed tomography angiography DKA Diabetic ketoacidosis FIB Fibrinogen PT Prothrombin Time Declarations Acknowledgements None. Authors’ contributions X.L.: Conceptualized and designed the study, acquired data, and drafted the manuscript. S.S.: Participated in clinical case identification and data acquisition. X.B.: Conceptualized and designed the study, performed critical revision of the manuscript, and provided final approval. All authors read and approved the final manuscript. Funding None. Data availability The patient data supporting the findings of this study are available from the authors. Data are, however, available from the authors upon reasonable request. Contact the corresponding author,Xuedong Bai (email: [email protected] ). Ethics approval and consent to participate The treatment was conducted ethically in accordance with the World Medical Association Declaration of Helsinki and the standard of practice in Cho Ray Hospital. The patient provided written informed consent to publish this case report and all the accompanying images. Consent for publication Written informed consent was obtained from the patient to publish this case report and any accompanying images. Competing interests The authors declare no competing interests. References Liang M, Xu J, Luo Y, Qu J. Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review. Ann Med. 2024 Sep 2;56(1):2396570. Yang N, Zhang L, Feng S. Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies. J Fungi. 2023 May 19;9(5):592. Czech MM, Cuellar-Rodriguez J. Mucormycosis. Infect Dis Clin North Am. 2025 Mar;39(1):121–44. Lynch JP, Fishbein MC, Abtin F, Zhanel GG. Part 1: mucormycosis: prevalence, risk factors, clinical features, and diagnosis. Expert Rev Anti Infect Ther. 2023;21(7):723–36. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021;15(4):102146. Shih HI, Huang YT, Wu CJ. Disease burden and demographic characteristics of mucormycosis: a nationwide population-based study in taiwan, 2006–2017. Mycoses. 2022 Nov;65(11):1001–9. Osaigbovo II, Ekeng BE, Davies AA, Oladele RO. Mucormycosis in Africa: epidemiology, diagnosis and treatment outcomes. Mycoses. 2023 Jul;66(7):555–62. Vasudevan B, Hazra N, Shijith K, Neema S, Vendhan S. Mucormycosis: the scathing invader. Indian J Dermatol. 2021 Jul;66(4):393–400. Sengupta I, Nayak T. Coincidence or reality behind mucormycosis, diabetes mellitus and covid-19 association: a systematic review. J Mycol Medicale. 2022 Aug;32(3):101257. Dailey Garnes NJM, Kontoyiannis DP. Mucormycosis: update on clinical presentation, diagnosis, and treatment. Curr Opin Infect Dis. 2023 Dec;36(6):427–35. Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SCA, Dannaoui E, Hochhegger B, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the european confederation of medical mycology in cooperation with the mycoses study group education and research consortium. 2021; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 Mar, 2026 Reviewers agreed at journal 11 Mar, 2026 Reviewers invited by journal 09 Mar, 2026 Editor invited by journal 10 Feb, 2026 Editor assigned by journal 07 Feb, 2026 Submission checks completed at journal 07 Feb, 2026 First submitted to journal 06 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8807863\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":604421562,\"identity\":\"cca68814-46b8-445f-a995-02c8d13a5763\",\"order_by\":0,\"name\":\"Xinyu Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Chengde Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xinyu\",\"middleName\":\"\",\"lastName\":\"Li\",\"suffix\":\"\"},{\"id\":604421563,\"identity\":\"7ede6a08-2963-404e-9a79-378e5a67fef6\",\"order_by\":1,\"name\":\"Shaolong Shen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Chengde Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shaolong\",\"middleName\":\"\",\"lastName\":\"Shen\",\"suffix\":\"\"},{\"id\":604421564,\"identity\":\"abe7156a-a2bd-4489-900d-6960a4000df0\",\"order_by\":2,\"name\":\"Xuedong Bai\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACAzDJBsTsjY0PP5Cmhedws7EEaVok0tsEeIjRYi6RYybxocwmTz7yYRuDBIOdnG4DAS2WM9LSJGecSys2vJ3Y9qCAIdnY7AAhh91IPibN23Y4cePsxHYDCYYDidsIa0lsk/4L0jLzYJsED3FagLYwArXMl2AkVsuZZ8mWPefSEjfwJAID2YAYvxzPMbzxo8wmcX778YcPP1TYyRHUwiCQANULVmlASDkI8EMNlW8gRvUoGAWjYBSMSAAAQ6hGP+3gy4cAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Chengde Medical University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Xuedong\",\"middleName\":\"\",\"lastName\":\"Bai\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-06 13:54:43\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8807863/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8807863/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":104557479,\"identity\":\"d6ba8f87-5a10-423d-962d-75e4211795a6\",\"added_by\":\"auto\",\"created_at\":\"2026-03-13 09:27:44\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":162367,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eA-C:Non-contrast chest CT demonstrate multiple consolidations and ground-glass opacities in the right upper lobe and left lower lobe, distributed along the bronchovascular bundles. Bronchial wall thickening is present. The halo sign is observed in the right upper lobe lesion(black arrow).\\u003c/p\\u003e\\n\\u003cp\\u003eD-F:Follow-up CT obtained 3 days later demonstrates marked progression of the bilateral lung lesions. The reversed halo sign is observed in some lesions (white arrow). New multiple ill-defined nodules are noted in the left lung , accompanied by a small right pleural effusion.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8807863/v1/238192a85cd9c19eadb6b05d.png\"},{\"id\":104557558,\"identity\":\"4c7c4657-0590-4d81-9aad-310a1095b58b\",\"added_by\":\"auto\",\"created_at\":\"2026-03-13 09:28:03\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":455177,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eChest computed tomography pulmonary angiography (CTPA) revealed complete vascular occlusion of the right upper lobe pulmonary artery, along with filling defects and attenuated opacification in the left upper lobe, right middle lobe, and bilateral lower lobes.(blue, veins; yellow, arteries)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8807863/v1/338396d4ccb47e1c65710fb2.png\"},{\"id\":104557686,\"identity\":\"5ca262ed-8014-41ae-ba97-780995a07e7a\",\"added_by\":\"auto\",\"created_at\":\"2026-03-13 09:28:34\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":857979,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8807863/v1/0d40a6e9-8cb8-46d1-bd46-3f55596608da.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Fulminant Angioinvasive Pulmonary Rhizomucorosis in Diabetic Ketoacidosis: a case report\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eMucormycosis is an invasive fungal infection caused by fungi of the order Mucorales(1). Clinically, it is classified into various forms based on the site of involvement, including rhino-orbital-cerebral, pulmonary, gastrointestinal, and cutaneous presentations(1,2). The disease predominantly affects immunocompromised individuals and often follows a rapidly progressive course(3,4). Patients with DKA represent a particularly high-risk group, as the associated hyperglycemia and metabolic acidosis create a conducive pathophysiological environment for fungal proliferation.(5)\\u003c/p\\u003e \\u003cp\\u003eThe diagnosis of pulmonary mucormycosis is particularly formidable, as its early clinical manifestations and radiological features frequently mimic those of severe bacterial pneumonia, leading to potential diagnostic ambiguity.This diagnostic ambiguity often leads to significant delays in initiating appropriate antifungal therapy. We present a case of rapidly progressive pulmonary mucormycosis in a young female with DKA, highlighting how its resemblance to common community-acquired pneumonia complicates early recognition.\\u003c/p\\u003e\"},{\"header\":\"Case presentation\",\"content\":\"\\u003cp\\u003eA 30-year-old female farmer presented to the emergency department with an 8-day history of cough, sputum production, and fever, followed by one day of progressive dyspnea. She had a history of elevated blood glucose but had not received regular follow-up or glycemic control. Prior treatment at a local clinic with azithromycin and cephalosporins had been ineffective.\\u003c/p\\u003e \\u003cp\\u003eOn physical examination, the patient was tachycardic (140 bpm) and tachypneic (30 breaths/min). Auscultation revealed bilateral dry and moist crackles. Arterial blood gas analysis indicated severe metabolic acidosis with respiratory failure (pH 6.90, PaO₂ 95 mmHg, PaCO₂ 13 mmHg). Coagulation profiles showed a Prothrombin Time (PT) of 13.10 sec, Activated Partial Thromboplastin Time (APTT) of 37.30 sec, Fibrinogen (FIB) of 5.703 g/L, and D-Dimer of 0.87 \\u0026micro;g/mL.\\u003c/p\\u003e \\u003cp\\u003eChest computed tomography (CT) demonstrated multiple patchy opacities in the bilateral perihilar regions (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). CTA revealed absent opacification of the right upper lobe pulmonary artery and faint opacification of branches in the left upper lobe, right middle lobe, and bilateral lower lobes, suggestive of vascular involvement (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Additionally, cranial CT demonstrated multiple punctate hypodensities in the left watershed area, findings potentially associated with disseminated fungal infection. Magnetic resonance imaging (MRI) was not performed due to the patient's unstable clinical condition.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eLaboratory results confirmed community-acquired pneumonia, type I respiratory failure, and DKA. Emergent endotracheal intubation and mechanical ventilation were initiated. Pathogen testing revealed elevated Mycoplasma pneumoniae IgM (1.552 S/CO) and IgG (33.653 AU/ml), as well as influenza A IgM (8.195 S/CO). Initial empiric treatment included moxifloxacin, doxycycline, and oseltamivir. However, sputum culture subsequently grew Rhizomucor spp.. Consequently, doxycycline was discontinued (as Mycoplasma RNA was negative), and amphotericin B cholesterol sulfate complex (250 mg daily) was added to the regimen. Unfortunately, the patient\\u0026rsquo;s condition was deemed too unstable for surgical debridement.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis case highlights the catastrophic synergy between uncontrolled metabolic dysregulation and invasive fungal infection. While Mucorales are ubiquitous, invasive disease is rare and predominantly affects immunocompromised hosts(6). Diabetes mellitus is the most significant risk factor globally, associated with a mortality rate of up to 46%(5). In our patient, previously undiagnosed diabetes and severe ketoacidosis (HbA1c 14.3%) created a precipitating environment for Rhizomucor proliferation, confirming that metabolic status is a critical determinant of disease progression.\\u003c/p\\u003e \\u003cp\\u003eThe susceptibility of DKA patients to mucormycosis is mechanically distinct(7). Hyperglycemia and acidosis directly impair neutrophil chemotaxis and macrophage phagocytosis, the host's primary defenses against fungi(8). Furthermore, Mucor species thrive in acidic, glucose-rich environments and express ketone reductase, allowing them to flourish during ketoacidosis(9). This unique angioinvasive nature was clinically evident in our case through the rapid deterioration of respiratory function and the vascular involvement observed on CTA.\\u003c/p\\u003e \\u003cp\\u003eThe primary clinical challenge lies in the nonspecific presentation of pulmonary mucormycosis, which frequently mimics severe bacterial pneumonia or tuberculosis(10). In this case, the diagnosis was obscured by the patient\\u0026rsquo;s initial presentation of fever and cough, alongside positive serology for Mycoplasma pneumoniae, leading to an initial focus on community-acquired pneumonia. This highlights a critical pitfall: in high-risk patients (e.g., those with DKA), co-infection or misleading serological markers should not preclude the investigation of invasive fungal disease when response to standard antibiotics is poor.\\u003c/p\\u003e \\u003cp\\u003eEarly recognition requires a multidisciplinary approach. While chest CT findings such as the \\\"vascular cut-off sign\\\" (as seen in our patient\\u0026rsquo;s right upper lobe pulmonary artery) are highly suggestive of fungal angioinvasion, they are not pathognomonic. Therefore, definitive diagnosis relies heavily on obtaining deep respiratory specimens. Histopathological identification of broad, pauciseptate hyphae with right-angle branching remains the gold standard(10). Clinicians must maintain a high index of suspicion in diabetic patients presenting with pulmonary consolidation to initiate life-saving antifungal therapy and surgical evaluation without delay.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eConclusion Early symptoms of mucormycosis are often nonspecific. When patients with high-risk underlying conditions present with acute severe pulmonary infection, clinicians should maintain a high index of suspicion for mucormycosis. Diagnosis should be pursued through a multidisciplinary approach combining imaging and etiological studies for early confirmation. Treatment should be tailored based on individual patient factors, balancing antifungal therapy and surgical intervention to improve outcomes. Intravenous amphotericin B is the first-line treatment, while posaconazole or isavuconazole may be considered for patients intolerant to amphotericin B(11). Surgical debridement of infected tissue can improve prognosis, although it was not feasible in this case due to extensive pulmonary involvement.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAPTT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eActivated Partial Thromboplastin Time\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eComputed tomography\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCTA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eComputed tomography angiography\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eDKA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eDiabetic ketoacidosis\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eFIB\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eFibrinogen\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eProthrombin Time\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eAcknowledgements\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;None. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors’ contributions\\u003c/p\\u003e\\n\\u003cp\\u003eX.L.: Conceptualized and designed the study, acquired data, and drafted the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eS.S.: Participated in clinical case identification and data acquisition.\\u003c/p\\u003e\\n\\u003cp\\u003eX.B.: Conceptualized and designed the study, performed critical revision of the manuscript, and provided final approval.\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eNone.\\u003c/p\\u003e\\n\\u003cp\\u003eData availability\\u003c/p\\u003e\\n\\u003cp\\u003eThe patient data supporting the findings of this study are available from the authors. Data are, however, available from the authors upon reasonable request. Contact the corresponding author,Xuedong Bai \\u0026nbsp; (email: hyxuedong@163.com).\\u003c/p\\u003e\\n\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe treatment was conducted ethically in accordance with the World Medical Association Declaration of Helsinki and the standard of practice in Cho Ray Hospital. The patient provided written informed consent to publish this case report and all the accompanying images.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication \\u0026nbsp;Written informed consent was obtained from the patient to publish this case report and any accompanying images.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting interests \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eLiang M, Xu J, Luo Y, Qu J. Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review. Ann Med. 2024 Sep 2;56(1):2396570.\\u003c/li\\u003e\\n\\u003cli\\u003eYang N, Zhang L, Feng S. Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies. J Fungi. 2023 May 19;9(5):592.\\u003c/li\\u003e\\n\\u003cli\\u003eCzech MM, Cuellar-Rodriguez J. Mucormycosis. Infect Dis Clin North Am. 2025 Mar;39(1):121\\u0026ndash;44.\\u003c/li\\u003e\\n\\u003cli\\u003eLynch JP, Fishbein MC, Abtin F, Zhanel GG. Part 1: mucormycosis: prevalence, risk factors, clinical features, and diagnosis. Expert Rev Anti Infect Ther. 2023;21(7):723\\u0026ndash;36.\\u003c/li\\u003e\\n\\u003cli\\u003eSingh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021;15(4):102146.\\u003c/li\\u003e\\n\\u003cli\\u003eShih HI, Huang YT, Wu CJ. Disease burden and demographic characteristics of mucormycosis: a nationwide population-based study in taiwan, 2006\\u0026ndash;2017. Mycoses. 2022 Nov;65(11):1001\\u0026ndash;9.\\u003c/li\\u003e\\n\\u003cli\\u003eOsaigbovo II, Ekeng BE, Davies AA, Oladele RO. Mucormycosis in Africa: epidemiology, diagnosis and treatment outcomes. Mycoses. 2023 Jul;66(7):555\\u0026ndash;62.\\u003c/li\\u003e\\n\\u003cli\\u003eVasudevan B, Hazra N, Shijith K, Neema S, Vendhan S. Mucormycosis: the scathing invader. Indian J Dermatol. 2021 Jul;66(4):393\\u0026ndash;400.\\u003c/li\\u003e\\n\\u003cli\\u003eSengupta I, Nayak T. Coincidence or reality behind mucormycosis, diabetes mellitus and covid-19 association: a systematic review. J Mycol Medicale. 2022 Aug;32(3):101257.\\u003c/li\\u003e\\n\\u003cli\\u003eDailey Garnes NJM, Kontoyiannis DP. Mucormycosis: update on clinical presentation, diagnosis, and treatment. Curr Opin Infect Dis. 2023 Dec;36(6):427\\u0026ndash;35.\\u003c/li\\u003e\\n\\u003cli\\u003eCornely OA, Alastruey-Izquierdo A, Arenz D, Chen SCA, Dannaoui E, Hochhegger B, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the european confederation of medical mycology in cooperation with the mycoses study group education and research consortium. 2021;\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pulmonary-medicine\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pulm\",\"sideBox\":\"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pulm/default.aspx\",\"title\":\"BMC Pulmonary Medicine\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pulmonary mucormycosis, Rhizomucor, Diabetes\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8807863/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8807863/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eBackground\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eInfections by Rhizomucor species are aggressive invasive fungal diseases primarily affecting metabolically compromised hosts. Pulmonary involvement is diagnosticially challenging due to nonspecific clinical and radiological features, often leading to fatal delays.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCase presentation\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eWe report a rapidly progressive case in a 30-year-old female with undiagnosed diabetic ketoacidosis (DKA). Initially mismanaged as community-acquired pneumonia due to misleading serological markers, the patient quickly developed type I respiratory failure. Diagnosis was confirmed via sputum culture and Chest computed tomography angiography (CTA), the latter revealing pathognomonic vascular involvement.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusion\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eThis case underscores the necessity of a high clinical suspicion for mucormycosis in DKA patients, emphasizing that early etiological identification and prompt antifungal therapy are critical for survival.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Fulminant Angioinvasive Pulmonary Rhizomucorosis in Diabetic Ketoacidosis: a case report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-13 09:24:36\",\"doi\":\"10.21203/rs.3.rs-8807863/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"337283475535298123885560011671449393977\",\"date\":\"2026-03-12T06:39:34+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"130853343272047956104993599131236308010\",\"date\":\"2026-03-11T10:03:55+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-09T07:08:42+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-10T07:08:57+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-07T14:16:40+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-07T14:16:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Pulmonary Medicine\",\"date\":\"2026-02-06T13:24:59+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pulmonary-medicine\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pulm\",\"sideBox\":\"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pulm/default.aspx\",\"title\":\"BMC Pulmonary Medicine\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"2cc253fc-16c0-44ee-b534-028af1ebe76c\",\"owner\":[],\"postedDate\":\"March 13th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-13T09:24:36+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-13 09:24:36\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8807863\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8807863\",\"identity\":\"rs-8807863\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}