Long-term Survival After Cessation of Treatment for Rhino-Orbito-Cerebral Mucormycosis

ABSTRACT

Introduction: A patient with progressive rhino-orbito-cerebral mucormycosis (ROCM) despite maximal therapy survived 2 months after complete discontinuation of treatment. A 35-year-old man with poorly controlled diabetes presented to outside hospital with severe headaches, cough, and hyperglycemia. He was found to be COVID-19 positive and in severe diabetic ketoacidosis. He received neither corticosteroids nor monoclonal antibodies for COVID-19. Empiric therapy with intravenous (IV) antibiotics, antivirals, and antifungals was initiated. Endoscopic sinus debridement revealed fungal invasion;pathology confirmed mucormycosis. Subsequent imaging showed disease progression with intracranial extension despite maximal treatment. The patient elected to stop all treatment and was discharged with home hospice. He continued only metformin and did not make a concerted effort toward glycemic control. After 2 months he presented to Loma Linda Hospital with right eye symptoms;imaging showed persistent disease. IV antibiotics and antifungals were initiated. After endoscopic evaluation and debridement, tissue pathology showed residual mucormycosis. The patient was discharged home after 16 days with a 6-week course of meropenem and lifelong posaconazole. Method(s) A PubMed search for English-language case reports and series from 2000 to present was performed using search terms mucormycosis, survive, rhino-orbitocerebral, rhino-cerebral, and cerebral. Result(s) No reports of long-term survival after discontinuation of therapy were identified. Conclusion(s) This case illustrates a rare situation in which a patient whose ROCM progressed despite maximal therapy survived for over 2 months after halting treatment. ROCM mortality is as high as 85%. Outcomes are improved with surgical and antifungal therapy, and there are many reports of survival with ongoing treatment. However, there appear to be no documented cases of survival with active disease after termination of therapy. This patient's unsuccessful management and 2-month treatment hiatus make his long-term survival surprising.