Isolated cerebral mucormycosis: A case discussion

Abstract

We report a case of a 32-year-old male with a history of type 1 diabetes, inhaled drug use, and alcohol use disorder, who presented with encephalopathy, holocranial headaches, neck pain, confusion, and generalized tonic-clonic seizures. The patient initially presented at a rural community hospital with a fever and was found to be in diabetic ketoacidosis (DKA). He was also hemodynamically stable but stuporous, prompting intubation to protect his airway. Despite initial treatment measures, his neurological condition worsened and he remained ventilator-dependent. Key findings include a high glucose level, presence of ketones, and evidence of drug use. Blood cultures showed no growth, but his febrile state persisted. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis, hyperglycorrhachia but normal protein, with no growth. Neuroimaging showed right hemispheric slowing on EEG and diffusion restriction in the right frontal lobe on MRI. The patient's neurological status worsened on the second day of admission, manifesting as sluggish pupillary reflexes, right third nerve palsy, and decerebrate posturing. Emergent MRI suggested cerebral edema, leading to initiation of hypertonic saline. This case highlights the diagnostic challenges and critical management considerations in a patient with multiple comorbidities presenting with unexplained neurological deterioration, emphasizing the importance of a comprehensive and timely approach to diagnosis and treatment.

Keywords: Diabetes; Drug abuse; Infection; Mucormycosis.

Fig. 1

A: MRI Brain w/wo Contrast: Diffusion restricting lesions in right frontal lobe with FLAIR signal abnormality in the right basal ganglia and anterior limb of internal capsule and associated small foci of petechial hemorrhage. Associated local mass effect with sulcal effacement, partial effacement of right lateral ventricle, and minimal right-to-left midline shift without pathologic intracranial enhancement. B: New diffusion restricting lesions in left basal ganglia. Marked progression of right frontal lobe cytotoxic and vasogenic edema with worse leftward midline shift (9 mm), effacement of the third ventricle, obstructive hydrocephalus, and subfalcine herniation without intracranial enhancement.

Fig. 2

A: High-power magnification of brain tissue stained with Periodic Acid-Shiff (PAS) showing characteristic pauciseptate ribbon-like hyphae with wide angle branching, suggestive of mucormycosis. B: Medium-power magnification of brain tissue stained with Grocott’s Methenamine Silver (GMS) showing black colored Mucor hyphae.