Objective:

To describe a rare case of rhino-orbital-cerebral mucormycosis (ROCM) with simultaneous internal carotid artery (ICA) occlusion and bilateral internal jugular vein (IJV) thrombosis in a nonketotic diabetic patient, emphasizing early recognition of vascular complications in the emergency setting.

Background:

ROCM is a fulminant, angioinvasive fungal infection classically associated with diabetic ketoacidosis (DKA). The infection can lead to arterial or venous thrombosis through direct vascular invasion, resulting in ischemic strokes or cavernous sinus thrombosis. Concurrent arterial and venous occlusion in the absence of ketoacidosis, however, remains exceedingly rare and carries a poor prognosis.

Design/Methods:

A 37-year-old man with newly diagnosed, untreated diabetes mellitus presented with fever, right periorbital swelling, left hemiparesis, and altered mental status. Imaging revealed a malignant right MCA infarct with proximal ICA occlusion and bilateral IJV thrombosis. Nasal endoscopy showed necrotic mucosa, and KOH mount confirmed mucormycosis. The patient was started on liposomal amphotericin B and broad-spectrum antibiotics. Despite multidisciplinary management, neurological status declined, culminating in brain death secondary to extensive vascular invasion.

Results:

This case demonstrates an unusual dual vascular involvement: arterial (ICA occlusion causing malignant MCA infarct) and venous (bilateral IJV thrombosis), in ROCM without ketoacidosis. The pathogenesis involves fungal hyphal invasion of vascular endothelium, resulting in thrombosis, infarction, and tissue necrosis. Early bedside POCUS and CT angiography were instrumental in identifying this vascular compromise. ROCM should therefore be considered in diabetics presenting with orbital cellulitis and acute ischemic stroke, even in the absence of ketoacidosis.

Conclusions:

ROCM can present with stroke-like features even in nonketotic diabetics. Early mycologic confirmation and prompt antifungal initiation are critical. Emergency physicians and neurologists should maintain vigilance for this rapidly fatal but potentially recognizable disease.