Rhino-orbito-cerebral mucormycosis in a 42-year-old type II diabetes patient: a case report from Ethiopia

Rhino-orbito-cerebral mucormycosis in a 42-year-old type II diabetes patient: a case report from Ethiopia | 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 Rhino-orbito-cerebral mucormycosis in a 42-year-old type II diabetes patient: a case report from Ethiopia Haftu Zinabu Kassa, Elias Ababulgu Abadiko, Tewodros Deneke Belete, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6999639/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mucormycosis is a severe fungal infection that can progress quickly with high mortality, primarily affecting individuals with weakened immune systems, such as those with retroviral infections or cancer. Symptoms vary by infection site, with rhino-orbito-cerebral mucormycosis presenting nasal congestion and facial swelling, pulmonary mucormycosis causing cough and chest pain, cutaneous mucormycosis resulting in skin lesions, and gastrointestinal mucormycosis leading to abdominal issues. This case report highlights a case of a 42-year-old patient with type II diabetes mellitus presenting with facial swelling and visual loss of 12 days duration, which developed after tooth extraction. Case presentation: A 42-year-old Ethiopian woman who is a known patient with type II diabetes mellitus that claims to be adherent to her oral anti-diabetic medications presented with facial swelling, visual loss, and a right-sided spastic type of hemiplegia, all after decayed tooth extraction. She denied having a history of chronic headache, thyroid disease, trauma, or any other chronic medical disorders. On physical examination, she was acutely sick-looking with blood pressure of 130/80 mmHg, a pulse rate of 112 beats per minute, a respiratory rate of 26 breaths per minute, a temperature of 38°C, oxygen saturation of 93% at room air, and a body mass index of 21 kg/m². Further evaluation revealed a black eschar in the hard palate, while evaluations of the respiratory system, cardiovascular system, abdomen, musculoskeletal system, and other neurologic evaluations were unremarkable. Investigations with neck and head CT scans showed a hyperdense lesion involving bilateral maxillary sinuses and the right fronto-ethmoidal sinus that was later confirmed to be rhino-cerebral mucormycosis, with hypodensity in the right basal ganglia, temporal, and frontal cortex. Conclusion: Mucormycosis is a serious fungal illness that can quickly cause disability and death. A high level of attention is required, particularly in patients at risk of immunological compromise, including those with diabetes mellitus, to initiate appropriate therapy and prevent morbidity and death. An early multidisciplinary approach is critical for effective care. Furthermore, good diabetes control combined with improved periprocedural care, including possible antibiotics, may decrease invasive fungal infections. oral lesions cerebral mucormycosis diabetes mellitus focal neurologic deficit Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Key Teaching Points Mucormycosis, or zygomycosis, is a severe fungal infection primarily affecting individuals with compromised immune systems, such as those with diabetes or undergoing immunosuppressive therapy. Symptoms vary by infection site, including nasal congestion and headaches for rhinocerebral mucormycosis, cough and chest pain for pulmonary mucormycosis, skin lesions for cutaneous mucormycosis, and abdominal distress for gastrointestinal mucormycosis. Key risk factors include uncontrolled diabetes, immunosuppression, and chronic health conditions. Diagnosis relies on clinical evaluations and imaging, while treatment typically involves antifungal medications, surgical debridement, and management of underlying health issues. Due to its rapid progression and high mortality rate if untreated, early diagnosis and treatment are crucial. Introduction Mucormycosis is a rare, aggressive, fungal opportunistic infection mainly affecting immunocompromised hosts. It is caused by Mucorales; the commonest genera in human beings are Rhizopus and Mucor. The first clinical case of rhino-cerebral mucormycosis was reported by Paultauf in 1885 ( 1 – 3 ). It is an Angio-invasive infection that characteristically causes tissue necrosis in the involved tissue. Rhino-orbito-cerebral is the commonest presentation, followed by pulmonary and cutaneous. Rhino-orbit cerebral is acquired by the inhalation of spores. Commonly affected individuals are those with Diabetes mellitus with Diabetes ketoacidosis, Hematopoietic cell transplantation, and solid organ transplantation ( 4 – 6 ). The usual clinical presentation is as an acute ѕiոսѕitiѕ with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Mucormycosis is a highly fatal disease. The mainstay of treatment is early initiation of antifungal therapy and surgical debridement of the dead tissue. Early diagnosis and treatment are the main determinants of survival ( 3 , 7 ). Case presentation A 42-year-old Ethiopian woman who is a known patient with type II diabetes mellitus on oral metformin 1 gm on twice daily and oral glibenclamide 5 mg daily for the last 3 years, was referred to Jimma University Hospital with facial swelling and visual loss of 12 days duration, which was after decayed tooth extraction. She had pain while eating, itching, and a foreign body sensation in the left eye that progressed to visual loss. Later, she developed right-sided body weakness. She denied having a history of chronic headache, thyroid disease, trauma, or any other chronic medical disorders. On physical examination, she was acutely sick looking with mild change in mental status, and with blood pressure of 130/80 mmHg, pulse rate of 112 beats per minute, respiratory rate of 26 breaths per minute, temperature of 38 0 C, oxygen saturation of 93% at room air, and body mass index of 21 kg/m2. Further evaluation revealed a black eschar in the hard palate, dry lips, a cloudy eyeball with decreased tone in the left side, and a dilated fixed pupil in the right side (Fig. 1 ). Motor examination reveals power of 0/5 on the right side, both upper and lower, while the left side was intact. Other evaluations, including the respiratory system, cardiovascular system, abdominal, and musculoskeletal system, were unremarkable. Investigations on presentation showed random blood sugar of 460 mg/dl, with ketosis of + 3, glycosylated hemoglobin A1 was 7.5%, serum potassium level of 2.5-2.63-5.19 mg/dl, serum sodium of 145 mg/dl, while renal function tests were within normal limit, serum creatinine being 0.62 mg/dl with blood urea nitrogen of 16 mg/dl. Cerebrospinal fluid analysis was clear, with no cells, no growth on culture for bacteria and fungi, while complete blood count was normal; total white blood cells were 9.8×10 3 cells/µl, hemoglobin was 14.8 g/dl, and platelets were 307×10 3 /µl. Neck and head CT scan showed hyperdense lesion involving bilateral maxillary sinuses, right fronto-ethmoidal sinus, that later confirmed to be rhino-cerebral mucormycosis, with hypodensity in the right basal ganglia, temporal and frontal cortex (Fig. 2 and Fig. 4 (Follow-up brain and sinus CT-scan after 6 weeks of treatment showing chronic infarction involving basal ganglia, frontal and temporal cortex (top and bottom panels), and destroyed left maxillary bone post treatment). Histopathology from the debrided tissue showed broad-based, irregularly branching at 90°, non-septate, ribbon-like fungal hyphae with necrotic tissue and inflammatory cells in the background, typical of mucormycosis (Fig. 3). Management and follow-up She was treated empirically with intravenous ceftriaxone, 2 g twice daily, with intravenous vancomycin 1 g, twice daily, together with intravenous metronidazole 500 mg, three times daily for 10 days, while completing investigations including blood culture. As the patient was not responding to the empiric treatment, the antibiotics were revised to intravenous meropenem 1 g twice daily. Diabetic ketoacidosis was also treated with intravenous fluid as per active guidelines, and insulin was administered per the protocol for the management of diabetic ketoacidosis, so as hypokalemia, which was treated with potassium 40 mEq/ml over 4 hours, three times daily, that led to normalization. Intravenous Liposomal amphotericin-B, 8 mg daily, was initiated and continued for eight weeks, which was accompanied by debridement of the dead tissue in the hard palate, from which the sample for microscopy and culture was sent. After six weeks of treatment, she had significant clinical and radiologic (Fig. 4 ) improvement, with clear mentation. Despite the late presentation and poor prognostic features, the patient survived with major disability, right-sided hemiparesis, and vision loss, while diabetic follow-up was continued regularly. Discussion Mucormycosis is an uncommon, aggressive, and opportunistic infection caused by the order Mucorales. In the United States, it is believed that there are 1.7 cases per million people, while India and Pakistan have 140 cases per million people. Rhizopus, Mucor, Absidia, and Cunninghamella are the most prevalent genera in human infections. These creatures are commonly found in rotting vegetation and soil. They disperse spores into the air, making them airborne. In susceptible people, the fungus is contracted by inhaling sporangiospores; the infection usually starts in the nasal turbinates ( 1 , 3 , 4 ). Diabetic patients frequently appear with rhino-orbital illness. Mucormycosis agents are angioinvasive, hence tissue necrosis is a defining feature of the disease ( 6 – 8 ). The majority of patients with rhino-cerebral mucormycosis have diabetes mellitus, with or without diabetic ketoacidosis as a risk factor; for pulmonary and cutaneous mucormycosis, hematologic malignancy, organ transplantation, and immunosuppressive medication delivery are also common risk factors. Additionally, a study found a link between COVID-19 and mucormycosis ( 9 ). Rhino-cerebral mucormycosis causes acute sinusitis with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. All sinuses get infected and can spread to nearby regions such as the mouth, orbit, and brain, usually within a few days ( 1 , 7 ). The spread from the sphenoid sinuses to the adjacent cavernous sinus can cause cranial nerve palsies, sinus thrombosis, and carotid artery involvement. Histopathology provides a clear diagnosis. There will be broad-based, non-septate hyphae that branch at 90°, with necrotic tissue in the backdrop. Imaging studies such as CT scans and MRIs of the sinuses can reveal hyperdense changes in the sinuses as well as tissue destruction; extension to the cavernous sinus may result in cavernous sinus thrombosis; and extension to the brain parenchyma may result in ischemia in the frontal, temporal lobe, and deep brain structures. Early treatment includes the injection of antifungal medicines such as amphotericin B (ideally liposomal amphotericin B) at a dose of 5–10 mg/kg IV daily. When a patient has central nervous system affection, it is preferable to administer the maximum dose of liposomal amphotericin-B of 10 mg/kg ( 1 , 8 ). When amphotericin B is not available or is hazardous, isavuconazole or posaconazole can be used instead ( 3 , 10 ). Treatment includes adequate and multiple debridement of dead tissue, blood sugar correction, and diabetic ketoacidosis care. The timing of surgery and treatment of diabetic ketoacidosis has no meaningful impact on overall survival ( 3 , 5 , 10 ). Untreated patients have a terrible prognosis, with a survival rate of only 3%. Early diagnosis and delivery of systemic antifungal medicines result in significant survival benefits: 61% if treatment begins within the first 12 days of presentation, compared to 33% if begun after 13 days. Patients discovered early, treated with systemic antifungals, and surgical debridement may have a survival rate of up to 70%. Infection with Cunninghamella species, as well as widespread disease, hemiplegia, facial necrosis, and cerebral affection, are poor prognostic indications of rhino-cerebral mucormycosis ( 2 , 5 , 11 ). Conclusion Mucormycosis is a serious fungal illness that can quickly cause disability and death. A high level of attention is required, particularly in patients at risk of immunological compromise, including those with diabetes mellitus, to initiate appropriate therapy and prevent morbidity and death. An early multidisciplinary approach is critical for effective care. Furthermore, good diabetes control combined with improved periprocedural care, including possible antibiotics, may decrease invasive fungal infections. Abbreviations CT: Computed tomography MD: Medical Doctor MRI: Magnetic Resonance Imaging Declarations Ethics approval and consent to participate This case report and review of the literature conducted involving human participants received approval from the appropriate ethical commission, and written informed consent was obtained from the participants for both participation and the publication of identifiable images or data. Clinical Trial Not applicable Consent for publication The written informed consent was obtained from the participant for both participation and the publication of identifiable images or data in this manuscript. Competing interests The authors affirm that their research was carried out without any commercial or financial relationships that might be seen as potential conflicts of interest. Funding The authors declare that no funding was provided from any government or non-government organization for this work. Author Contribution The paper was conceived and written collaboratively by authors KNT, MDJ, EHG, and MLK, with HZK taking the lead on the initial draft. The analysis of the cases involved contributions from KNT, HZK, MDJ, MLK, EAA, EHG, TDB and TDB, while all authors participated in the revision process and approved the final manuscript. Acknowledgements Authers is grateful for the Jimma University Hospital Medical ward staff for their collaboration during compiling the data for this manuscript. Data Availability The study includes original contributions, which are detailed in the article and supplementary material, with further inquiries directed to the corresponding authors based on need. References 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. Volume 19. The Lancet Infectious Diseases; 2019. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Volume 41. Clinical Infectious Diseases; 2005. Dave TV, Gopinathan Nair A, Hegde R, Vithalani N, Desai S, Adulkar N, et al. Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) following COVID-19: A Multi-Centric Study. Ophthalmic Plast Reconstr Surg; 2021. Kumar M, Alagarsamy R, Madi M, Pentapati KC, Vineetha R, Shetty SR, et al. Rhinocerebral mucormycosis: a systematic review of case reports and case series from a global perspective. Volume 134. Oral Medicine, Oral Pathology and Oral Radiology: Oral Surgery; 2022. Vaughan C, Bartolo A, Vallabh N, Leong SC. A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis—has anything changed in the past 20 years? Clin Otolaryngol. 2018;43(6). Alanazi RF, Almalki A, Alkhaibary A, AlSufiani F, Aloraidi A. Rhino-Orbital-Cerebral Mucormycosis: A Rare Complication of Uncontrolled Diabetes. Case Rep Surg. 2022;2022. Alqarihi A, Kontoyiannis DP, Ibrahim AS. Mucormycosis in 2023: an update on pathogenesis and management. Vol. 13, Frontiers in Cellular and Infection Microbiology. 2023. Rhino-orbital mucormycosis. Our experiences with clinical features and management in a tertiary care center. Rom J Ophthalmol. 2022;65(4). Hoenigl M, Seidel D, Carvalho A, Rudramurthy SM, Arastehfar A, Gangneux JP, et al. The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries. Volume 3. The Lancet Microbe; 2022. Bhansali A, Bhadada S, Sharma A, Suresh V, Gupta A, Singh P, et al. Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes. Postgrad Med J. 2004;80:949. Patel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S et al. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect. 2020;26(7). Additional Declarations No competing interests reported. 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2","display":"","copyAsset":false,"role":"figure","size":444457,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTop panels\u003c/strong\u003e: Hyperdense lesions in the maxillary sinus (green arrow: right upper), sphenoidal sinus (green arrow: middle upper), \u003cstrong\u003eand \u003c/strong\u003eethmoidal sinus (green arrow: left upper). \u003cstrong\u003eBottom panels\u003c/strong\u003e: Shows hypodense areas consistent with ischemia in basal ganglia (right lower), mesial temporal lobe (middle lower), and frontal and parietal cortex (left lower).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6999639/v1/8a71979511fb8807520408b1.png"},{"id":88534681,"identity":"574a4a20-e777-4369-961a-c5a442940ca7","added_by":"auto","created_at":"2025-08-07 12:20:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1059103,"visible":true,"origin":"","legend":"\u003cp\u003eHematoxylin and eosin stain from the debrided tissue showed broad-based, irregularly branching at 90°, non-septate, ribbon-like fungal hyphae with necrotic tissue and inflammatory cells in the background, typical of mucormycosis.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6999639/v1/6776c434bded589a2158b540.png"},{"id":88534291,"identity":"e5cea8cb-6324-45e4-ad1d-7b8b91744e3c","added_by":"auto","created_at":"2025-08-07 12:12:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":380584,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up brain and sinus CT-scan after 6 weeks of treatment revealed chronic infarction involving basal ganglia, frontal and temporal cortex (the two pictures), and destroyed left maxillary bone (the last one)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6999639/v1/999d00ecb1ebc0135aa9a8b7.png"},{"id":89824247,"identity":"c3de1d80-921b-4938-b1a6-7ec5e1bd637d","added_by":"auto","created_at":"2025-08-25 12:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3330249,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6999639/v1/77d339e3-0ce9-42a5-bd2c-2ac191fd4a6c.pdf"},{"id":88535893,"identity":"f96f4340-5a21-44ba-bff4-075e2c8b4786","added_by":"auto","created_at":"2025-08-07 12:36:38","extension":"rar","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1699488,"visible":true,"origin":"","legend":"","description":"","filename":"Video.rar","url":"https://assets-eu.researchsquare.com/files/rs-6999639/v1/e1ff3f8c04fcd3a8f6b5036b.rar"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rhino-orbito-cerebral mucormycosis in a 42-year-old type II diabetes patient: a case report from Ethiopia","fulltext":[{"header":"Key Teaching Points","content":"\u003cul\u003e\n \u003cli\u003eMucormycosis, or zygomycosis, is a severe fungal infection primarily affecting individuals with compromised immune systems, such as those with diabetes or undergoing immunosuppressive therapy.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSymptoms vary by infection site, including nasal congestion and headaches for rhinocerebral mucormycosis, cough and chest pain for pulmonary mucormycosis, skin lesions for cutaneous mucormycosis, and abdominal distress for gastrointestinal mucormycosis.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKey risk factors include uncontrolled diabetes, immunosuppression, and chronic health conditions.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDiagnosis relies on clinical evaluations and imaging, while treatment typically involves antifungal medications, surgical debridement, and management of underlying health issues.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDue to its rapid progression and high mortality rate if untreated, early diagnosis and treatment are crucial. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eMucormycosis is a rare, aggressive, fungal opportunistic infection mainly affecting immunocompromised hosts. It is caused by Mucorales; the commonest genera in human beings are Rhizopus and Mucor. The first clinical case of rhino-cerebral mucormycosis was reported by Paultauf in 1885 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is an Angio-invasive infection that characteristically causes tissue necrosis in the involved tissue. Rhino-orbito-cerebral is the commonest presentation, followed by pulmonary and cutaneous. Rhino-orbit cerebral is acquired by the inhalation of spores. Commonly affected individuals are those with Diabetes mellitus with Diabetes ketoacidosis, Hematopoietic cell transplantation, and solid organ transplantation (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The usual clinical presentation is as an acute ѕiոսѕitiѕ with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Mucormycosis is a highly fatal disease. The mainstay of treatment is early initiation of antifungal therapy and surgical debridement of the dead tissue. Early diagnosis and treatment are the main determinants of survival (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA 42-year-old Ethiopian woman who is a known patient with type II diabetes mellitus on oral metformin 1 gm on twice daily and oral glibenclamide 5 mg daily for the last 3 years, was referred to Jimma University Hospital with facial swelling and visual loss of 12 days duration, which was after decayed tooth extraction. She had pain while eating, itching, and a foreign body sensation in the left eye that progressed to visual loss. Later, she developed right-sided body weakness. She denied having a history of chronic headache, thyroid disease, trauma, or any other chronic medical disorders. On physical examination, she was acutely sick looking with mild change in mental status, and with blood pressure of 130/80 mmHg, pulse rate of 112 beats per minute, respiratory rate of 26 breaths per minute, temperature of 38\u003csup\u003e0\u003c/sup\u003e C, oxygen saturation of 93% at room air, and body mass index of 21 kg/m2. Further evaluation revealed a black eschar in the hard palate, dry lips, a cloudy eyeball with decreased tone in the left side, and a dilated fixed pupil in the right side (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMotor examination reveals power of 0/5 on the right side, both upper and lower, while the left side was intact. Other evaluations, including the respiratory system, cardiovascular system, abdominal, and musculoskeletal system, were unremarkable.\u003c/p\u003e\u003cp\u003eInvestigations on presentation showed random blood sugar of 460 mg/dl, with ketosis of + 3, glycosylated hemoglobin A1 was 7.5%, serum potassium level of 2.5-2.63-5.19 mg/dl, serum sodium of 145 mg/dl, while renal function tests were within normal limit, serum creatinine being 0.62 mg/dl with blood urea nitrogen of 16 mg/dl. Cerebrospinal fluid analysis was clear, with no cells, no growth on culture for bacteria and fungi, while complete blood count was normal; total white blood cells were 9.8×10\u003csup\u003e3\u003c/sup\u003e cells/µl, hemoglobin was 14.8 g/dl, and platelets were 307×10\u003csup\u003e3\u003c/sup\u003e /µl.\u003c/p\u003e\u003cp\u003eNeck and head CT scan showed hyperdense lesion involving bilateral maxillary sinuses, right fronto-ethmoidal sinus, that later confirmed to be rhino-cerebral mucormycosis, with hypodensity in the right basal ganglia, temporal and frontal cortex (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e (Follow-up brain and sinus CT-scan after 6 weeks of treatment showing chronic infarction involving basal ganglia, frontal and temporal cortex (top and bottom panels), and destroyed left maxillary bone post treatment).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHistopathology from the debrided tissue showed broad-based, irregularly branching at 90°, non-septate, ribbon-like fungal hyphae with necrotic tissue and inflammatory cells in the background, typical of mucormycosis (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eManagement and follow-up\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eShe was treated empirically with intravenous ceftriaxone, 2 g twice daily, with intravenous vancomycin 1 g, twice daily, together with intravenous metronidazole 500 mg, three times daily for 10 days, while completing investigations including blood culture. As the patient was not responding to the empiric treatment, the antibiotics were revised to intravenous meropenem 1 g twice daily. Diabetic ketoacidosis was also treated with intravenous fluid as per active guidelines, and insulin was administered per the protocol for the management of diabetic ketoacidosis, so as hypokalemia, which was treated with potassium 40 mEq/ml over 4 hours, three times daily, that led to normalization. Intravenous Liposomal amphotericin-B, 8 mg daily, was initiated and continued for eight weeks, which was accompanied by debridement of the dead tissue in the hard palate, from which the sample for microscopy and culture was sent. After six weeks of treatment, she had significant clinical and radiologic (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e) improvement, with clear mentation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDespite the late presentation and poor prognostic features, the patient survived with major disability, right-sided hemiparesis, and vision loss, while diabetic follow-up was continued regularly.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMucormycosis is an uncommon, aggressive, and opportunistic infection caused by the order Mucorales. In the United States, it is believed that there are 1.7 cases per million people, while India and Pakistan have 140 cases per million people. Rhizopus, Mucor, Absidia, and Cunninghamella are the most prevalent genera in human infections. These creatures are commonly found in rotting vegetation and soil. They disperse spores into the air, making them airborne. In susceptible people, the fungus is contracted by inhaling sporangiospores; the infection usually starts in the nasal turbinates (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Diabetic patients frequently appear with rhino-orbital illness. Mucormycosis agents are angioinvasive, hence tissue necrosis is a defining feature of the disease (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe majority of patients with rhino-cerebral mucormycosis have diabetes mellitus, with or without diabetic ketoacidosis as a risk factor; for pulmonary and cutaneous mucormycosis, hematologic malignancy, organ transplantation, and immunosuppressive medication delivery are also common risk factors. Additionally, a study found a link between COVID-19 and mucormycosis (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Rhino-cerebral mucormycosis causes acute sinusitis with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. All sinuses get infected and can spread to nearby regions such as the mouth, orbit, and brain, usually within a few days (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The spread from the sphenoid sinuses to the adjacent cavernous sinus can cause cranial nerve palsies, sinus thrombosis, and carotid artery involvement. Histopathology provides a clear diagnosis. There will be broad-based, non-septate hyphae that branch at 90°, with necrotic tissue in the backdrop. Imaging studies such as CT scans and MRIs of the sinuses can reveal hyperdense changes in the sinuses as well as tissue destruction; extension to the cavernous sinus may result in cavernous sinus thrombosis; and extension to the brain parenchyma may result in ischemia in the frontal, temporal lobe, and deep brain structures.\u003c/p\u003e\u003cp\u003eEarly treatment includes the injection of antifungal medicines such as amphotericin B (ideally liposomal amphotericin B) at a dose of 5–10 mg/kg IV daily. When a patient has central nervous system affection, it is preferable to administer the maximum dose of liposomal amphotericin-B of 10 mg/kg (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). When amphotericin B is not available or is hazardous, isavuconazole or posaconazole can be used instead (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Treatment includes adequate and multiple debridement of dead tissue, blood sugar correction, and diabetic ketoacidosis care. The timing of surgery and treatment of diabetic ketoacidosis has no meaningful impact on overall survival (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUntreated patients have a terrible prognosis, with a survival rate of only 3%. Early diagnosis and delivery of systemic antifungal medicines result in significant survival benefits: 61% if treatment begins within the first 12 days of presentation, compared to 33% if begun after 13 days. Patients discovered early, treated with systemic antifungals, and surgical debridement may have a survival rate of up to 70%. Infection with Cunninghamella species, as well as widespread disease, hemiplegia, facial necrosis, and cerebral affection, are poor prognostic indications of rhino-cerebral mucormycosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMucormycosis is a serious fungal illness that can quickly cause disability and death. A high level of attention is required, particularly in patients at risk of immunological compromise, including those with diabetes mellitus, to initiate appropriate therapy and prevent morbidity and death. An early multidisciplinary approach is critical for effective care. Furthermore, good diabetes control combined with improved periprocedural care, including possible antibiotics, may decrease invasive fungal infections.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eCT: Computed tomography\u003c/li\u003e\n \u003cli\u003eMD: Medical Doctor\u003c/li\u003e\n \u003cli\u003eMRI: Magnetic Resonance Imaging\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This case report and review of the literature conducted involving human participants received approval from the appropriate ethical commission, and written informed consent was obtained from the participants for both participation and the publication of identifiable images or data.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical Trial\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003e The written informed consent was obtained from the participant for both participation and the publication of identifiable images or data in this manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors affirm that their research was carried out without any commercial or financial relationships that might be seen as potential conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors declare that no funding was provided from any government or non-government organization for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe paper was conceived and written collaboratively by authors KNT, MDJ, EHG, and MLK, with HZK taking the lead on the initial draft. The analysis of the cases involved contributions from KNT, HZK, MDJ, MLK, EAA, EHG, TDB and TDB, while all authors participated in the revision process and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eAuthers is grateful for the Jimma University Hospital Medical ward staff for their collaboration during compiling the data for this manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe study includes original contributions, which are detailed in the article and supplementary material, with further inquiries directed to the corresponding authors based on need.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\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. Volume 19. The Lancet Infectious Diseases; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Volume 41. Clinical Infectious Diseases; 2005.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDave TV, Gopinathan Nair A, Hegde R, Vithalani N, Desai S, Adulkar N, et al. Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) following COVID-19: A Multi-Centric Study. Ophthalmic Plast Reconstr Surg; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar M, Alagarsamy R, Madi M, Pentapati KC, Vineetha R, Shetty SR, et al. Rhinocerebral mucormycosis: a systematic review of case reports and case series from a global perspective. Volume 134. Oral Medicine, Oral Pathology and Oral Radiology: Oral Surgery; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVaughan C, Bartolo A, Vallabh N, Leong SC. A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis\u0026mdash;has anything changed in the past 20 years? Clin Otolaryngol. 2018;43(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlanazi RF, Almalki A, Alkhaibary A, AlSufiani F, Aloraidi A. Rhino-Orbital-Cerebral Mucormycosis: A Rare Complication of Uncontrolled Diabetes. Case Rep Surg. 2022;2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlqarihi A, Kontoyiannis DP, Ibrahim AS. Mucormycosis in 2023: an update on pathogenesis and management. Vol. 13, Frontiers in Cellular and Infection Microbiology. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRhino-orbital mucormycosis. Our experiences with clinical features and management in a tertiary care center. Rom J Ophthalmol. 2022;65(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoenigl M, Seidel D, Carvalho A, Rudramurthy SM, Arastehfar A, Gangneux JP, et al. The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries. Volume 3. The Lancet Microbe; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhansali A, Bhadada S, Sharma A, Suresh V, Gupta A, Singh P, et al. Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes. Postgrad Med J. 2004;80:949.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S et al. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect. 2020;26(7).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"oral lesions, cerebral mucormycosis, diabetes mellitus, focal neurologic deficit, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-6999639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6999639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Mucormycosis is a severe fungal infection that can progress quickly with high mortality, primarily affecting individuals with weakened immune systems, such as those with retroviral infections or cancer. Symptoms vary by infection site, with rhino-orbito-cerebral mucormycosis presenting nasal congestion and facial swelling, pulmonary mucormycosis causing cough and chest pain, cutaneous mucormycosis resulting in skin lesions, and gastrointestinal mucormycosis leading to abdominal issues. This case report highlights a case of a 42-year-old patient with type II diabetes mellitus presenting with facial swelling and visual loss of 12 days duration, which developed after tooth extraction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 42-year-old Ethiopian woman who is a known patient with type II diabetes mellitus that claims to be adherent to her oral anti-diabetic medications presented with facial swelling, visual loss, and a right-sided spastic type of hemiplegia, all after decayed tooth extraction. She denied having a history of chronic headache, thyroid disease, trauma, or any other chronic medical disorders. On physical examination, she was acutely sick-looking with blood pressure of 130/80 mmHg, a pulse rate of 112 beats per minute, a respiratory rate of 26 breaths per minute, a temperature of 38°C, oxygen saturation of 93% at room air, and a body mass index of 21 kg/m². Further evaluation revealed a black eschar in the hard palate, while evaluations of the respiratory system, cardiovascular system, abdomen, musculoskeletal system, and other neurologic evaluations were unremarkable. Investigations with neck and head CT scans showed a hyperdense lesion involving bilateral maxillary sinuses and the right fronto-ethmoidal sinus that was later confirmed to be rhino-cerebral mucormycosis, with hypodensity in the right basal ganglia, temporal, and frontal cortex.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Mucormycosis is a serious fungal illness that can quickly cause disability and death. A high level of attention is required, particularly in patients at risk of immunological compromise, including those with diabetes mellitus, to initiate appropriate therapy and prevent morbidity and death. An early multidisciplinary approach is critical for effective care. Furthermore, good diabetes control combined with improved periprocedural care, including possible antibiotics, may decrease invasive fungal infections.\u003c/p\u003e","manuscriptTitle":"Rhino-orbito-cerebral mucormycosis in a 42-year-old type II diabetes patient: a case report from Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 12:12:33","doi":"10.21203/rs.3.rs-6999639/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"811a24f9-d59f-4f25-8b7c-aee190c8e440","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T12:09:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-07 12:12:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6999639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6999639","identity":"rs-6999639","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}