A case of a Rhizopus infection in a patient with diabetes and fear
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CASE REPORT
A case of a Rhizopus infection in a patient with diabetes and fear Kelly Engle1 · Rani Shayto1 · Nicoleta Sora1 Received: 24 July 2020 / Accepted: 25 September 2020 © Springer-Verlag Italia S.r.l., part of Springer Nature 2020
Case report A 19-year-old female with history of type 1 diabetes mellitus (T1DM) on insulin pump therapy and anxiety presented to emergency department for pain and swelling of her upper arm at the site of her insulin pump that had progressed despite outpatient antibiotic courses. Patient’s T1DM was diagnosed at age 7 and maintained an HbA1c 7–8% up until a few years ago following an episode of diabetes ketoacidosis (DKA) and hypoglycemia during DKA treatment. She subsequently developed FoH and resisted outpatient insulin pump dose titrations, leading to an uncontrolled HbA1c of 13% and multiple recurring infections including pilonidal cysts and sinusitis. On admission, patient had a temperature of 38.7 degrees Celsius, heart rate of 175 beats per minute, and blood pressure of 122/87 mmHg. On physical exam, patient was anxious appearing, tachycardic, and had induration and erythema extending from left shoulder to elbow. Patient’s laboratories revealed WBC of 19 × 109/L and DKA with glucose of 440 mg/dL, beta-hydroxybutyrate of 5.1 mg/ dL, bicarbonate of 12 meq/L, sodium 135 meq/L, potassium 3.4 meq/L, and anion gap of 21. She initially refused hospital DKA insulin intravenous protocol as well as subcutaneous insulin injections. She had insulin pump competency and only allowed unadjusted insulin administration via her pump despite endocrinology consultants’ recommendations for intravenous insulin infusion. Vancomycin and piperacillin–tazobactam were started for empiric infectious coverage, and an incision and drainage of left upper extremity lesion was performed with cultures obtained. DKA worsened in the following hours with pH 7.18, anion gap of 18, and bicarbonate of 5 meq/L. Intravenous insulin infusion was eventually started with blood glucose target of 150–250 mg/dL Managed by Massimo Federici. * Kelly Engle [email protected] 1
Medical University of South Carolina, Charleston, SC, United States
per patient’s wishes. DKA persisted due to opposition of insulin titration per protocol calculator as a result of patient’s recurrent panic attacks. The upper arm infection continued to progress, and a CT scan was done showing no soft tissue gas but loss of fat plane concerning for necrotizing fasciitis. Wound culture from initial I&D resulted positive for Rhizopus fungus. Patient’s antimicrobial regimen was broadened to vancomycin, piperacillin–tazobactam, clindamycin, and amphotericin. She was taken to the OR for debridement for two consecutive days. Patient remained intubated after her second debridement and developed septic shock requiring vasopressor support. While intubated, she received standard DKA insulin protocol and achieved resolution of DKA. After four total surgical debridement operations and 5 days of intubation, she was able to be weaned off vasopressors and
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