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Leucocytosis and rhino-orbital-cerebral mucormycosis: case report A 70-year-old man developed leucocytosis and rhino-orbital-cerebral mucormycosis following treatment with decitabine and azacitidine for myelodysplastic syndrome (MDS) [routes and dosages not stated]. The man, who had MDS and diabetes mellitus presented with recent weakness, nosebleeds, falls and tooth pain. He was treated with decibatine for MDS. At the time of presentation, he had been receiving azacitidine [VIDAZA] for MDS. On admission, he was hyperglycaemic (uncontrolled DM) and insulin drip was started. He was eventually diagnosed with peri-apical abscess at the root of tooth #15 and a large carious erosion of the left mandibular molar involving the crown [aetiology not stated]. On the same day, both these teeth were extracted. Upon anamnesis, it was revealed that, although he had complaints of tooth pain for the last several months, the dental care was post-poned due to occurrence of chemotherapy-induced leucocytosis. During the tooth extraction, a black eschar developed rapidly on the hard palate. It became tender and grew in size during the procedure, however, it was not draining. Also, he developed right periorbital swelling. On further examination, an eschar extending to the nasal septum was identified. Therefore, a fungal smear was collected, which showed pauciseptate hyphae that indicated a zygomycete and a budding yeast, and he was hospitalised. The man was treated with amphotericin-B-liposomal, posaconazole and micafungin. An MRI of the head with contrast revealed acute invasive fungal rhino-orbital sinusitis and showed disseminated multifocal mycotic emboli in the brain. Culture revealed two distinct fungal colony morphologies. After 24h, a smooth colonies with feet were identified as Candida albicans. On day 5, the culture identified presence of Actinomucor species. Based on these findings, a diagnosis of rhino-orbital-cerebral mucormycosis was made. The chemotherapy with decitabine and azacitidine were considered as risk factors for development of rhino-orbitalcerebral mucormycosis [durations of treatments to reactions onsets not stated]. An extensive surgery, including enucleation and removal of nose/maxilla with combinational anti-fungal therapy was proposed for the rhino-orbital-cerebral mucormycosis. However, considering the poor prognosis of disseminated mucormycosis, he and his family decided to avoid extensive and painful surgery and opted for transfer to comfort care. Following 1h, he died [immediate cause of death not stated]. Kubica PA, et al. An unusual case of actinomucor elegans: A challenging diagnosis. American Journal of Case Reports 21: 15 May 2020. Available from: URL: https:// 803497546 pubmed.ncbi.nlm.nih.gov/32409629/

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Reactions 22 Aug 2020 No. 1818