Mucormycosis of Neck a Rare Presentation
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Mucormycosis is a dreaded clinical entity caused by filamentous fungi affecting immunocompromised individuals. A 43 year old male, initially presented with complaints of right sided earache, ear discharge and right facial palsy. He also had right sided tender neck swelling and oedema extending up to the cheek. Ear examination under microscope showed edema of external canal with perforated tympanic membrane. He gave history of insect entry into his right ear 2 weeks back which was removed on the same day at a local hospital. He is a known diabetic with uncontrolled sugars and not on any proper diabetic regimen. WBC counts and serum creatinine levels were elevated.

MRI imaging showed right mastoiditis and sigmoid sinus thrombosis extending to IJV with features of myositis and cellulitis of neck muscles. HRCT Temporal bone was done which showed only minimal mastoiditis without any evidence of bone erosion. The patient was put on empirical high end broad spectrum antibiotics. A repeat imaging was done and it showed a spreading cellulitis and thrombosis of right internal jugular vein with retropharyngeal space involvement. Neck exploration and IJV ligation was done.

Post operatively after initial 72 h of improvement, his condition again deteriorated with spreading facial cellulitis, chemosis of right eye and ophthalmoplegia. Hematology consultation was sought in view of total count reaching 49,000. The histopathology report arrived on 4th day, surprisingly showing mucor in the peripheral rim of fat tissue around lymph node with features of necrosis in periphery. Hence the diagnosis of invasive mucormycosis of neck was reached.

Parenteral liposomal amphotericin B 5 mg/kg/day along with oral posaconazole 4?×?200 mg/kg/dose were started. Extensive surgical debridement and antifungal therapy being the only option, there was a dilemma as to how to debride the neck further. Staged debridements under LA were continued till disease free limits were attained. The debridement was carried out till atlas and around the foramen magnum which was the end point of dissection. He was given tigecycline during the course of his treatment as he developed multidrug resistant Klebsiella pneumonia, following which he developed tigecycline induced arrhythmia and cardiac arrest which was treated by cardiology team. He underwent feeding jejunostomy for long term nutritional requirements.

Finally after 3 weeks, reasonably good dry granular superficial wound without microbial activity was attained which was confirmed by repeated swab cultures.