“Trilogy of sequential fungal infections in a diabetic male” ▪ Respirology Case Reports Volume 3, Issue 4, Article first published online: 18 NOV 2015

Diabetes is associated with depressed immune status. There is increased susceptibility to usual pneumonia as well as to opportunistic organisms like Mucor which normally do not produce disease in immunocompetent individuals despite their ubiquitous presence in the environment. Isolated case reports have shown co‐infection with Mucor and tuberculosis. The situation is particularly challenging when mucor infection develops while on treatment for tuberculosis as in our case report. Delays in diagnosis can increase mortality exponentially in mucormycosis. As a consequence a high index of suspicion, prompt diagnostic evaluation is necessary.

Case Report

A 68‐year‐old male presented to the emergency room with left‐sided pleuritic chest pain, productive cough, fever, and progressive breathlessness of 20‐day duration. He was a known diabetic on oral hypoglycemic agents for 20 years. A chest radiograph and computed tomography (CT) scan of the thorax performed prior to admission showed a left upper lobe consolidation (Fig. 1A,B,C). Sputum culture done at that time revealed growth of an extended spectrum beta lactamase producing Klebsiella pneumoniae. The patient was treated with parenteral Meropenem for two weeks. On arrival in the emergency department he was tachypneic with a peripheral blood oxygen saturation on room air of 86%. Laboratory investigations revealed evidence of diabetic ketoacidosis (Blood sugar‐316 mg/dl, urine ketones ++, Glycosylated hemoglobin [HbA1C]‐9.70), as well as anemia (hemoglobin [Hb]‐8.9 g/dl) and leucocytosis (14,800/mm3, 84% neutrophils). Repeat CT thorax showed a left upper lobe consolidation with a reverse halo sign (Fig. 1D,E). Common causes of reverse halo sign are enumerated in Table 1 .