Snapshot A 38-year-old female with a past medical history of diabetes presents to the ED in a ketoacidotic coma. HEENT exam reveals periorbital swelling, mucopurulent rhinorrhea, and a black necrotic spot over her nose. Sinus CT scan shows obliteration of the ethmoid, maxillary, sphenoid, and frontal sinuses. Biopsy samples from nasal eschar show foci of non-septate fungal hyphae which branch at wide angles. Introduction Classification mucormycetes mucor rhizopus absidia cunnighamella An invasive fungi causing a rhinocerebral infection characterized by hyphae growing in or around vessels Epidemiology risk factors acidosis diabetic ketoacidosis leukemia AIDS DM lymphomas Associated conditions frontal lobe abscesses paranasal swelling hemorrhage from nose and eyes Pathogenesis spores found in soil fungus penetrates through sinuses into brain fungi proliferate in blood vessel walls results in infarction and necrosis Presentation Symptoms headache facial pain may have cranial nerve involvement dyspnea persistent cough Physical exam black necrotic eschar on face Evaluation Laboratory irregular, non-septate hyphae branching at wide angles filamentous Diagnosis biopsy specimen of involved tissue Differential Aspergillosis Orbital celluitits Cutaneous anthrax Treatment Conservative hyperbaric oxygen indications adjunctive therapy mechanism higher O2 increases the neutrophils ability to kill Pharmacologic amphotericin B (must act quickly) indications any suspected case of mucormycosis mechanism damages cell wall of fungi side effects potentially lethal multiple organ damage possible nephrotoxicity hepatotoxicity cardiac arrhythmias electrolyte imbalances blood dyscrasias posaconazole indications second-line medication Operative surgical debridement indications after administration of amphotericin B or posaconazole removal of "fungas balls" Prognosis, Prevention, and Complications Prognosis poor mortality rate between 30-70% for rhinocerebral form mortality rate up to 90% in disseminated form