Lockdown loss - An unfortunate conundrum in fungal diagnosis during COVID time

ABSTRACT

Background:Mucormycosis is uncommon among individuals with no underlying risk factors. In children a subcutaneous maxillofacial presentation is common with entomophthoromycosis. Establishing the correct etiology is essential as ther- apeutic management differs for entomophthoromycosis and mucormycosis. In this background establishing diagnosis in a 13 year old patient presenting with a maxillofacial swelling with erosion was a challenge. Methods:A 13 year old male child presented with a 3 year history. It progressed from dry discharging lesions on right side of the face to flattening of the dorsum of the nose and currently regurgitation of fluids from the nose after inges- tion. Biopsy from the facial lesions, middle meatus and anterior ethmoid were received for fungal culture. Results:KOH – calcofluor examination of samples revealed aseptate fungal hyphae. In view of the clinical presentation and the preliminary microscopic finding, a diagnosis of entomophthoromycosis, probably basidiobolomycosis was made. However the colony morphology on SDA and the preliminary LPCB was not suggestive of basidiobolomycosis. Final identification as M. circinelloides was established based on slide culture and confirmed by sequencing at PGIMER. What confused the diagnosis even further was reporting by pathologists as broad septate fungal hyphae with granulom- atous reaction. Empirical therapy with itraconazole was based on the preliminary microbiological diagnosis. He was dis- charged on oral itraconazole pending final microbiological confirmation. Unfortunately he was lost to follow up due to COVID. Conclusions:Establishing etiology and timely intervention, medical and/or surgical are key to the successful recovery of patients with deep fungal infections. It involves a team effort.