Rhino-Orbito-Cerebral Mucormycosis in a Diabetic Patient with Idiopathic CD4+ Lymphocytopenia 251
[2,17]. This theoretical benefit was confirmed in a retro-
spective study comparing amphotericin B plus caspofun-
gin with amphotericin B alone and the benefit was par-
ticularly evident in patients with cerebral involvement
[18]. In spite of the critical role of early anti-fungal ther-
apy, surgery still constitutes the cornerstone for success-
ful treatment of ROCM, since this infection is associated
with angioinvasion and extensive necrosis that can im-
pair adequate antifungal therapy to affected tissues [15].
The extent of surgery is dictated by the patient’s indivi-
dual presentation but for maxillofacial infection increas-
ing emphasis is put in less disfiguring surgical proce-
dures [2]. Other therapeutic options for mucormycosis
include posaconazole rescue therapy [1], hyperbaric oxy-
gen [19], iron chelation with deferasirox [1] and the use
of several kinds of immunotherapy [20].
Our patient was not diagnosed early in the clinical
course, yet antifung al ther apy was quickly initiated, rapid
tapering of corticosteroid and aggressive glycaemic con-
trol were performed and surgery was done one day after
diagnosis. Due to finantial restrains amphotericin B de-
oxycolate was the initial therapeutic choice however,
once nephrotoxicity was present, liposomal amphotericin
B was started and caspofungin was later added, due to
poor therapeutic resp onse. Due to d isease ex tension, with
brain and bilateral orbital involvement, a choice was made
not to perform aggressive desfigurative surgery and a mi-
nimally invasive approach was done.
4. Conclusion
This case illustrates the difficulty in diagnosing a rare con-
dition with non-specific clinical manifestations. It also
underlines the importance of awareness for risk factors
and clinical features of mucormycosis. High index of sus-
picion, multidisciplinary approach, newer diagnostic and
treatment tools altogether should p ermit, in the future, an
improvement in the outcome of this devastating disease.
5. Acknowledgements
The authors greet all the professionals involved in man-
agement of the patient and thank Dr. Henrique Costa for
his article review.
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