Fatal Rhinocerebral Mucormycosis and Aspergillus flavus Coinfection Complicated by Internal Carotid Artery Arteritis: A Case Report.

Abstract

This case report describes a fatal case of rhinocerebral mucormycosis and Aspergillus flavus coinfection in a 63-year-old Saudi male with poorly controlled Type II diabetes and hypertension. The patient presented with a 2-day history of rapid right-sided facial swelling, blurred vision, and proptosis. Clinical examination revealed necrotic nasal mucosa and ophthalmoplegia, while laboratory tests showed critical hyperglycemia (RBS 500 mg/dL) and severe leukocytosis. CT and MRI imaging confirmed extensive invasive fungal sinusitis with spread into the right cavernous sinus and involvement of the internal carotid artery (ICA). This angioinvasive progression resulted in infectious ICA arteritis and multiple acute cerebral infarcts. Management involved high-dose liposomal amphotericin B (escalated to 7.5 mg/kg), functional endoscopic sinus debridement, and initially voriconazole, which was discontinued due to hemodynamic instability. Despite these aggressive interventions and histopathological confirmation of the mixed fungal infection, the patient's neurological status deteriorated, leading to mechanical ventilation and, ultimately, death. This case illustrates the lethal nature of rhinocerebral mucormycosis, particularly when complicated by vascular invasion and coinfection. In regions like Saudi Arabia, where diabetes prevalence is high, a high index of clinical suspicion and immediate metabolic and surgical intervention are vital, as prognosis remains exceptionally poor once the infection reaches the cavernous sinus.