case report

A Diabetic Man in the Era of COVID-19

Kleoniki Georgousi1*, Dimitra Provi1, Dionysios Nikitopoulos1, Athanasia Bisia1, Alexandros Lazarou1, Eftychia Pouliou1, Kalliopi Diamantopoulou2

1Internal Medicine Department, Peripheral General Hospital of Attica KAT, Greece

2Pathology Department, Peripheral General Hospital of Attica KAT, Greece

*Corresponding author: Kleoniki Georgousi, Infectious Diseases Consultant, Internal Medicine Department, Peripheral General Hospital of Attica KAT, Nikis Street 2, 14561, Greece

Received Date: 13 February 2023

Accepted Date: 17 February 2023

Published Date: 20 February 2023

Citation: Georgousi K, Provi D, Nikitopoulos D, Bisia A, Lazarou A, et al (2023) A Diabetic Man in the Era of COVID-19. Ann Case Report. 8: 1177. DOI:http//doi.org/10.29011/2574-7754.101177

Abstract

A 71-year-old man with medical history of uncontrolled diabetes mellitus, admitted to COVID-19 clinic with SARS- CoV-2 PCR test positive and dyspnea. After a few days of hospitalization he had an abrupt deterioration with decreased consciousness, facial enema with purple blue discoloration, ptosis, proptosis, facial palsy and necrotic eschars in the oral cavity. Brain MRI and necrotic tissue sample biopsy were conducted. Although MRI images were suspicious of Rhino-Orbito- Cerebral-Mucormycosis, the diagnosis was set from histopathology findings with dermis subcutaneous fat tissue infiltration of the filaments fungi “mucor”. The risk assessment of COVID-19 mucormycosis co-infection is a worrisome scenario for patients suffering from uncontrolled co-morbidities, such as diabetes mellitus.

Keywords: COVID-19; Mucormycosis; Central Nervous System Invasion

Introduction

Mucormycosis is an opportunistic infection with rapid and lethal progression caused by filamentous fungi belonging in the order mucorales. These filamentous fungi exist anywhere in the environment affecting patients with diabetes mellitus (mainly with keto-acidosis), lymphoma, leukaemia, prolonged treatment with corticosteroids, organ or stem-cell transplantation, burns and malnutrition. In the era of COVID-19, patients either hospitalized with active infection caused by SARS-CoV-2 and needs of supplemental oxygen, antiviral and corticosteroid therapy either post-hospitalized are prone to secondary fungal infections such as Mucormycosis. The Rhino-Orbito-Cerebral form of mucormycosis which is the most prevalent type of this fungal infection is prescribed in the context of SARS-CoV-2 / Mucormycosis co- infection in a diabetic patient.

Case

A 71-year-old man admitted to the COVID-19 clinic with polymerase chain reaction (PCR) test positive, referring shortness of breath when SARS-CoV-2 mutation BA.1 had begun to prevail in Greece. He had previously received two doses of SARS-CoV-2 vaccination. His medical history included uncontrolled diabetes mellitus, severe renal disease, amputation of his second toe of the right lower limb, percutaneous transluminal angioplasty, in the context of diabetic microangiopathy, and operated gastric cancer. On the clinical examination he was afebrile, hemodynamic stable with bilateral dry lung rhonchi and severe hypoxia (oxygen saturation in room air: 85%). His lung computed tomography (CT) showed peripheral infiltrates ground glass type of the lower lung lobes bilaterally. Immediately, he was started a therapeutic scheme of systemic corticosteroids and supplemental oxygen without intravenous remdesivir due to his pre-existing renal compromise. After a few days of hospitalization the patient had an abrupt clinical deterioration with decreased consciousness, right facial swelling with purple discoloration, right eyelid ptosis, proptosis and anisocoria for the right eye. Results of the laboratory examination at that time showed leucocytosis (29,100 cells/μl), lymphopenia (1,290 %), reduced absolute count of lymphocytes (380 cells/μL), increased C-reactive protein of 20,9 mg/dl and serum ferritin of 727 ng/mL. Subsequently, the patient underwent a lumbar puncture examination with no findings (zero cells/μL). Despite the fact of apyrexia, broad spectrum of antibiotics (piperacillin / tazobactam and linezolid) were started while the patient’s clinical condition continue to worse with bilateral eyelid and facial enema with blue discoloration (Figure 1). Neurological examination revealed altered consciousness, facial palsy indicative of VII nerve infiltration, weak reflexes and hypoaesthesia of the right arm, in the context of hemiparesis as a result of CNS involvement. Ophthalmological assessment demonstrated bilateral ptosis and proptosis and ocular motility restriction leading to total ophthalmoplegia as a result of III, IV, and VI nerve involvement. A brain magnetic resonance imaging (MRI) was conducted revealing bilateral nasal sinus mucosal thickening with fluid level in the sinus causing partial opacification, and on T2-weighted images bilateral hyperintense areas in temporal lobes mainly in the left temporal lobe, in the form of CNS ischemic damage. MRI images also revealed soft tissue swelling of malar with subcutaneous solid lesions growth, while the same lesions were shown in the right upper jaw along with mild heterogeneity of palate and oral cavity area. Maxillofacial surgery consultation was requested and revealed ischemic-necrotic eschars in the right infra orbital region and hard palate. Tissue samples of the necrotic lesions were sent for culture and histopathology. Due to increased suspicion of Rhino-Orbito-Cerebral-Mucormycosis, antifungal treatment (isavuconazole) was added in the previous antibiotic scheme. Although Amphotericin B is considered the treatment of choice in mucormycosis [1], the decision of antifungal monotherapy was made because of the patient’s pre-existing renal compromise. Histopathologic analyses of necrotic eschar of the infra orbital region and hard palate revealed degeneration and necrosis of the subcutaneous fat tissue with infiltration by a septate or semi septate, irregular, ribbon-like hyphae. In positions, there was development of one hypha across another as a result of hyphal folding. Special stains used like Haematoxylin-Eosin and Grocott- Gomori’s methenamine-silver which revealed the right broad- angle of branching (~90 degree) and wide hyphal width (Figure 2). In places, nerve infiltration and angioinvasion by the mentioned hyphae was noted. The conclusion of the histopathological examination was “image compatible with dermis-subcutaneous fat tissue infiltration of the filamentous fungi mucor”. Surgical debridement of the infected tissues was abandoned as therapeutic protocol due to severe patient’s condition and uncertain benefit. The patient died a couple of days later.

 

Figure 1: 71-year-old patient suffering from bilateral eyelid and facial purple-blue discoloration.