A tip from the nose: rhinocerebral mucormycosis in a patient with alcoholic liver cirrhosis and cocaine abuse, an uncommon association

Abstract

We present the case of a 28-year-old man with a long-standing history of cocaine abuse and Child-Pugh class C alcoholic liver cirrhosis who developed severe lower respiratory tract infection complicated with septic shock and multiple organ dysfunction. He was managed in the intensive care unit. On the eighth day after admission, he developed a nose discolouration, which was initially thought to be associated with high-dose vasopressors. Despite the reduction of vasopressors, the lesion progressed rapidly. It was later diagnosed as rhinocerebral mucormycosis. Amphotericin B was administered, but unfortunately the patient succumbed to the complications postinfection. The association between alcoholic liver cirrhosis and rhinocerebral mucormycosis should be known and prompt recognition warrants immediate treatment.

Keywords: adult intensive care; alcoholic liver disease; cirrhosis; infectious diseases.

Figure 1

A and B show a large area of an ecchymotic skin lesion on the nose and the perinasal area, a black eschar on the nasal bridge and scleral icterus can also be noted.

Figure 2

A and B show mucosal friability with bleeding and the presence of white hyphae.

Figure 3

Mucormycosis fungi can be seen with H&E staining as a non-septated, broad (10 µm thick), ribbon-like, grey–blue, pauciseptate hyphae, with a branching pattern of 45°–90°.

Figure 4

(A) Histologically, this a destructive and invasive organism that produces poorly defined areas of ischaemia with necrosis. Brisk neutrophilic infiltrate and areas of necrosis are common. (B) Gomori methenamine silver staining highlights the previously described morphology.