STUCK IN THE MUD

A young man has always been working in the field, like many of his peers who are from the countryside near Hanoi. He was diagnosed with epilepsy when he was 11 years old, and is on regular anti epileptic medication. Two months ago he decided to stop the anti-epileptic as he hasn't had a seizure for a long while - and soon after that one day while he was walking he had a fit, lost consciousness and fell into a peat bog*. He fell head first into the mud and only after a long while was he discovered and pulled out from the swamp.

*wet spongy ground of decomposing vegetation; has poorer drainage than a swamp; soil is unfit for cultivation but can be cut and dried and used for fuel

Few days later he started having a high fever, and gradually it evoluted into a myriad of symptoms - cough, sputum, breathlessness and also a stiff neck and endophthalmitis in one eye. The provincial hospital transferred him here to NHTD. He had multiple imaging done - chest x-ray showed a diffuse shadowing in both lungs. Thus, he was suspected to have inhaled the mud while he was unconscious. Querying multiple infection and aspiration pneumonia he was started on multiple antibiotics. Nevertheless two weeks have passed and he is still doing rather poorly.

We went down to see him in the general infectious disease ward. After putting the pieces of the story together, Heiman and Baz (another ID consultant from London) figured out the key -

Normally, aspiration pneumonia may be caused by anaerobes and gut flora (the bacteria generally present in food and the digestive tract) - but if what you have aspirated is mud - one must consider the possibility of fungus and mould. 

Ah, an unifying diagnosis: mucormycosis. Turns out some fungi and mould can be so invasive that even someone with a healthy immune system can fall ill, very ill.

He is started on intravenous amphotericin B and ideally also posaconazole (another anti-fungal, although it is highly probable that it is not available here. One must make do). Meanwhile, I asked about the value of adding flucytosine because of his potential meningeal involvement, but flucytosine is only useful with cryptococcal infection especially, not all fungi. I hope he gets better real soon.

*

Mucormycosis: a rare infection caused by organisms that belong to a group of fungi called Mucoromycotina in the order Mucorales. The symptoms of mucormycosis depend on where in the body the fungus is growing. Mucormycosis most commonly affects the sinuses or lungs. If the infection is not treated quickly, the fungus can spread throughout the body, and the infection is often fatal.

Further reading | Centers for Disease Control and Prevention: Mucormycosis