Mucormycosis in the Rhino-Cerebral Region in the Context of a Growth Hormone–secreting Pituitary Macroadenoma: A Case Report

Mucormycosis (MCM) is an infection caused by fungi of the order Mucorales, characterized by angioinvasion, tissue necrosis, hematogenous dissemination, and often adverse outcomes. A 33-year-old man with diabetes presented with rhinorrhea, proptosis, periorbital edema, and reduced visual acuity in the left eye for six weeks. Computed tomography showed left-sided rhinosinusitis, a subperiosteal abscess, and facial cellulitis. Septoplasty, maxillary antrostomy, ethmoidectomy, orbital decompression, and drainage were performed, along with empiric antibiotic therapy. Despite these measures, he developed vision loss, mydriasis, and ophthalmoplegia, requiring repeat debridement, during which direct examination of the material revealed filamentous fungi with coenocytic hyphae compatible with MCM; liposomal amphotericin B (L-AmB) was started. Culture confirmed Rhizopus spp. The patient reported an initial diabetic decompensation one year earlier with irregular insulin use, and had clinical signs suggestive of acromegaly, including enlargement of extremities, sleep apnea, and progressive visual field loss. Endocrine evaluation demonstrated panhypopituitarism, elevated GH and IGF-1, and gonadotropic and thyrotropic deficiencies, confirming the diagnosis. Pituitary MRI revealed a macroadenoma with suprasellar extension (2.4 × 2.3 × 3.2 cm), which was not surgically addressed due to the active infection. After 14 days of treatment, he developed cavernous sinus thrombosis and underwent a third surgical procedure with orbital exenteration and inferior turbinectomy. Given progressive worsening despite extensive surgical clearance and L-AmB, isavuconazole was added. Despite insulin administration, glycemic control was only achieved after starting octreotide, a somatostatin analog capable of inhibiting GH and IGF-1 secretion and increasing insulin sensitivity. After eight weeks of combined antifungal therapy, with clinical and radiological improvement, he was discharged on isavuconazole, which was stopped after one month, and he remains stable under outpatient follow-up for 14 months. MCM is a medical emergency, and the association with uncontrolled acromegaly worsened prognosis. Cure depends on a multidisciplinary approach including optimized antifungal therapy, aggressive surgical management, and control of the underlying risk condition—here requiring a somatostatin analog to treat acromegaly.