Rhino Cerebral Mucormycosis in Systemic Lupus Erythematosus
A 28-year-old female presented with pallor, swelling of face and legs with history of hematuria, oliguria, and diffuse hair loss. She was suspected to have systemic lupus erythematosus (SLE) and on investigation, she had anemia (hemoglobin 7.5 gm%), leucocytosis, elevated ESR, positive ANA (1:80) and dsDNA. Her renal function tests including 24 h urinary protein were normal, except presence of RBC deposits. The renal biopsy showed diffuse proliferative glomerulonephritis with immuno fluorescence pattern consistent with lupus nephritis. She was treated with monthly pulses of injection methylprednisolone along with daily oral prednisolone. Three months later, she developed ulceration over cheek and palate with discharge of pus. She started losing weight and developed gross edema of right half of face. On examination, she had a puckered ulcer with induration over right side of cheek and a whitish plaque on hard palate [Figures and ]. She also had lagophthalmos and right-sided facial palsy. Superinfection with mucormycosis was suspected, methylprednisolone was stopped, and a therapeutic curettage done from the plaque, the histopathological examination of which showed broad irregular hyphae consistent with mucormycosis []. The fungal culture yielded no growth. Patient was treated with inj. amphotericin B 0.6 mg/kg/day i.v. for 1 month and she improved. However, the improvement was not consistent as there was extension of ulceration over the palate. Surgical debridement was repeated, computed tomography (CT) brain and peripheral nervous system (PNS) showed erosion of palate and maxillary antrum []. Maxillectomy was performed and Inj. amphotericin B continued for 21 days, and she was continuously monitored for signs of drug-induced renal toxicity. The disease was controlled and the wound healed well []. Patient is being followed up with no recurrence till date (3 years since diagnosis).