Case Report: A diabetic ketoacidosis in adolescents complicated with rhino-orbital-cerebral mucormycosis.

BACKGROUND: Rhino-orbital-cerebral mucormycosis (ROCM) is an aggressive infection caused by Mucorales fungi, with rapid progression, high mortality, and disability. The insidious onset and atypical early symptoms predispose the condition to misdiagnosis or delayed diagnosis. There are no evidence-based guidelines for the diagnosis and treatment of mucormycosis in children. This case report describes the entire diagnostic and treatment process for a 14-year-old female patient with type 1 diabetes mellitus (T1DM) who developed ROCM following diabetic ketoacidosis (DKA). It highlights the key role of clinical pharmacists in multidisciplinary collaboration, pharmacological evaluation, antifungal regimen optimization, and medication monitoring.

CASE DESCRIPTION: A 14-year-old female patient was admitted to the hospital due to persistent chest pain for 5 days and was diagnosed with T1DM complicated with DKA. During the treatment of DKA, the patient suddenly developed high fever, nasal congestion, progressive eyelid and periorbital swelling, headache, and cranial nerve dysfunction. Plasma mNGS and nasal mucosa biopsy both detected Rhizopus delemar, confirming ROCM. The initial treatment was liposomal amphotericin B (5 mg/kg/d) combined with nasal endoscopic debridement, the infection was initially controlled. However, on the 16th day, anemia aggravated (Hb 84 g/L), and severe hypokalemia (K+ 2.41 mmol/L) occurred. After a multidisciplinary assessment led by a clinical pharmacist and completion of a 4-week course of liposomal amphotericin B, the treatment plan was adjusted to include oral isavuconazole and intranasal amphotericin B deoxycholate. Follow-up for 4 months, facial and periorbital swelling completely resolved, olfaction recovered, facial sensation partially recovered, and no significant adverse drug reactions occurred.

CONCLUSION: This case demonstrates that in adolescent patients with T1DM who develop ROCM following DKA, non-specific prodromal symptoms such as headache, facial swelling, and nasal congestion should be closely monitored. Early implementation of a multi-modal diagnostic approach combining mNGS and tissue biopsy is necessary. Based on organ function, drug toxicity, and pharmacokinetic characteristics, individualized antifungal regimens that balance efficacy and target organ protection should be formulated. Clinical pharmacists play a crucial role in the management of severe fungal infections by participating in diagnostic collaboration, regimen optimization, and continuous safety monitoring, thereby enhancing the scientificity, safety, and precision of treatment.