Mucormycosis in an Immunocompetent Host

Summary: An 18-year-old male with no past medical history presented with 7-weeks of left-sided nasal swelling. He was admitted to the otolaryngology (ENT) service given breathing impairment and altered vision following extensive outpatient ENT work-up. Outpatient management included prednisone, clindamycin, trimethoprim-sulfamethoxazole, wash-out, FNA, biopsy, and cultures, one of which grew scant fungus. The patient reported physical trauma and bee sting to the nose prior to symptom onset, and a remote history of fungal sinusitis. On exam, marked left nasal sidewall swelling extending to the medial canthus, with subtle hyperpigmentation was noted. Dermatology was consulted, and a 4-mm punch biopsy was taken. Hematoxalin and eosin stain demonstrated invasive mucormycosis with areas of necrosis. The patient was taken to the operating room for debridement and debulking of the underlying soft tissue mass, which was causing boney destruction. Treatment with amphotericin B liposome, posaconazole, and weekly endoscopy and debridement is ongoing. Work-up for immunodeficiency remains negative. Theoretical risk has been proposed concerning mucormycosis infection due to insect sting or bites, as bees can be carriers of mucor spores. Clinicians should maintain a high index of suspicion for mucormycosis in patients with treatment-resistant unilateral nasal swelling without obvious cutaneous change, even in immunocompetent hosts.