Case Presentation: Bell’s Palsy
A 51-year-old Iranian woman, living in Hormozgan province in southern Iran, was admitted to the hospital due to a troublesome medical history of poorly controlled diabetes mellitus. Her chief complaints included a splitting headache in the left frontal area, which had been present for the past week. She experienced no nausea or vomiting, but she exhibited sensitivity to light. Moreover, she faced an inability to close or wink her left eye, smile, make any unilateral facial expressions, or raise her left brow.
She was on medication for diabetes mellitus. In addition, she had also been prescribed metformin and gliclazide. There was no history of drug allergies. Her overall appearance indicated that she was unwell, although her vital signs were normal. During the physical examination, doctors found a yellow-grey eschar measuring 1 by 1 cm in diameter. This was discreetly present on the left side of her hard palate. This, coupled with her neurological symptoms, immediately raised suspicions of mucormycosis as a potential diagnosis.
Investigation: Bell’s Palsy
To investigate this further, doctors conducted laboratory tests, revealing a significant increase in white blood cell count (WBC), estimated sedimentation rate (ESR), C-reactive protein (CRP), haemoglobin subunit alpha (HbA1C), and a decrease in haemoglobin (HB). All other findings from these tests were unremarkable.
The doctors also performed a spiral paranasal sinus computed tomography (CT) scan without contrast. This revealed a near-total opacification of the left maxillary sinus, left nasal cavity, and left ethmoidal sinus. Notably, mucosal thickening was observed in nearly all paranasal sinuses, with bony erosion evident in the medial and posterior walls of the left maxillary sinus. Following this, the medical team initiated treatment with amphotericin-B and promptly scheduled an ear, nose, and throat (ENT) consultation. Consequently, the patient underwent immediate functional endoscopic sinus surgery.
Biopsy results from the hard palate and mucosa indicated necrotic tissue hosting numerous broad, nonseptate ribbon-like fungal hyphae—a clear indication of mucormycosis infection.
Management
To combat this, the doctors commenced a treatment regimen involving amphotericin B deoxycholate, administered at a dosage of 1 mg/kg/day, sustained over a month, along with three rounds of debridement.
However, despite this medical approach, her persistent headache raised further concerns. As a result, doctors performed a comprehensive diagnostic workup, including brain magnetic resonance imaging (MRI) without contrast, brain magnetic resonance venography (MRV), and brain magnetic resonance angiography (MRA). Her headache, left eye discomfort, and facial movement began showing signs of improvement after one month of hospital treatment.
The doctors discharged the patient with a prescription for posaconazole (200 mg every 6 hours), gabapentin (100 mg every night) for a three-month duration, and the initiation of insulin therapy. A follow-up appointment three months later revealed a successful eradication of the infection.
Mucormycosis: Caused by Diabetes Mellitus
Mucormycosis is a fungal infection caused by a group of opportunistic moulds called mucormycetes. These organisms find their way into the respiratory tract through inhalation, contaminated food, and broken skin barriers, colonizing various regions. Nasal turbinates serve as the primary site for this colonization, and given their close proximity to the orbit, sinuses, and cerebrum, the infection can manifest in a myriad of ways.
Bell’s palsy is one of the most prevalent cranial nerve diseases, characterized by facial nerve palsy. It manifests as abrupt unilateral facial muscle weakness. It is often accompanied by drooling, tenderness behind the ear, tingling sensations in the ipsilateral cheek, and alterations in taste and volume perception. This condition affects individuals across the spectrum, regardless of age or gender. In mild cases, it manifests as a temporary struggle to perform basic oral functions, and in more severe cases, it manifests as an inability to seal their eyelids, inevitably leading to facial asymmetry.
Mucormycosis, caused by Mucorales, is found in soil, bread, and dust. This disease, while opportunistic and relatively rare, can often be very aggressive, often targeting immunocompromised patients.
Mucormycosis has a high mortality rate, with some case series documenting rates as high as 80%. Therefore, a swift and accurate diagnosis is essential to ensuring that there are no lifelong disabilities in the patient. The diagnostic process typically involves a combination of histopathology and tissue culture. This fungus can cause seven distinct syndromes in various locations, including but not limited to the rhino-orbital cerebral, pulmonary, gastrointestinal, central nervous system, cutaneous, miscellaneous, and disseminated manifestations. The recommended management plan for mucormycosis involves the administration of amphotericin B-lipomal type. However, this treatment is very expensive and often not available in resource-limited settings.
