Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 14

14 - INVASIVE RHINOCEREBRAL MUCORMYCOSIS LEADING TO GRADENIGO'S SYNDROME IN TYPE I DIABETIC

Thursday, Apr 25
12:30 PM – 1:00 PM

Objective : Rhinocerebral mucormycosis is a rare complication of sinusitis in diabetic patients and has fatal consequences if not recognized early. We present the first case of rhinocerebral mucormycosis leading to Gradenigo’s syndrome in a type I diabetic.


Methods : N/A.


Results : A 22-year-old female, poorly-controlled type I diabetic presented with neck stiffness, ear pressure and confusion. She was found to be tachycardic, tachypneic and had right-sided jaw tenderness. She was in diabetic ketoacidosis. CT neck showed retropharyngeal edema and cellulitis. She developed acute right gaze preference and left hemiparesis on the third day and brain MRI showed acute infarction of right frontal, parietal, occipital lobes and right internal carotid artery occlusion. On day six, she developed full right facial nerve paralysis, necrotic tympanic membrane and thick mucoid fluid in middle ear. Nasopharyngeal biopsy, ethmoidectomy and tympanoplasty were performed. Culture grew Mucor species and Amphotericin B was initiated. Given patient’s trigeminal neuralgia, otitis media and cranial nerve six palsy, she was diagnosed with Gradenigo’s Syndrome. Repeat brain MRI showed acute right parietal hemorrhage, temporal lobe abscess, and cavernous sinus thrombosis. Biopsy confirmed invasive Mucor. Meropenem, Amphotericin B and Posaconazole were continued extensively


Discussion :

Mucormycosis is the third most common life-threatening fungal infection, after candidiasis and aspergillosis.  It is caused by Zygomycetes; most frequently Rhizopus, Lichtheimia or Mucor.  Infections occur from spore inhalation or via direct inoculation of skin. After spores infect the paranasal sinuses, invasion may extend to sphenoid, cavernous sinus or cranially. Cavernous sinus involvement leads to cranial nerve palsies; thrombi of the carotid artery may cause  intracranial thrombosis with possible infarction and hemorrhage. While MRI assesses intracranial extent, diagnosis is confirmed with paranasal sinus biopsy. Treatment includes Amphotericin B and surgical debridement.

Gradenigo’s syndrome is a rare complication of otitis media, characterized by suppurative otitis media, facial pain in trigeminal nerve distribution and abducens nerve palsy. In suppurative otitis media, petrous part of temporal bone becomes infected and extends to the trigeminal ganglion and abducens nerve. Sequelae include meningitis, intracranial and parapharyngeal abscess. Treatment involves prolonged high-dose systemic and topical antibiotics or antifungals. 


Conclusion : Suspicion for Mucormycosis is required in poorly controlled diabetics presenting with sinusitis, headache or vision changes as delayed therapy is fatal with serious complications.

SHORT URL FUNCTION-->

Olesya Petrenko

Resident Physician
Sarasota Memorial Hospital

Enthusiastic resident physician from Sarasota Memorial Hospital, hoping to pursue Endocrinology as a fellowship.

Talal Alkayali

Resident Physician
Sarasota Memorial Hospital

Resident at Sarasota Memorial Hospital.

Belissa M. Ramos Chaves

Resident Physician
Sarasota Memorial Hospital

Resident at Sarasota Memorial Hospital.

Wilhelmine Wiese-Rometsch

Program Director
Florida State University College of Medicine

Supportive and knowledgeable program director of Internal Medicine at Sarasota Memorial Hospital.

Olesya Petrenko

Resident Physician
Sarasota Memorial Hospital

Enthusiastic resident physician from Sarasota Memorial Hospital, hoping to pursue Endocrinology as a fellowship.