Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressive and indolent condition often characterized by nonspecific symptoms at onset, which can result in delayed diagnosis and the development of severe complications. We report a case presenting with HHS/DKA, left orbital apex syndrome due to invasive fungal sinusitis, and multiple neuropathies. Despite aggressive surgical debridement, antifungal therapy, and ongoing ophthalmologic monitoring, he remains at risk for further complications, including potential orbital exenteration. A 45-year old male who has not sought medical care in the past 20 years and has no significant past medical history presented with progressive bilateral leg pain and swelling impairing his ability to walk. He reported that his leg pain and weakness has been ongoing for the past 3 years. Additionally, he experienced left facial swelling with decreased vision in his left eye beginning two days prior. On examination, he appeared ill with generalized cachexia and sarcopenia. The left side of his face was swollen with facial droop, although forehead muscle movement remained intact. He exhibited left-sided ptosis with purulent discharge and loss of abduction in the left eye. Furthermore, he had decreased sensation on the left side in V1 and V2 distributions. Laboratory results revealed leukocytosis, anion gap metabolic acidosis, and a glucose level of 810. His urine contained 15 mg/dL ketones and >1000 mg/dL glucose. His HbA1c was >20% with a C-peptide level < 0.2 ng/ml. Due to high clinical suspicion of invasive sinusitis, the patient was promptly started on empiric treatment with amphotericin B, vancomycin and meropenem. Abdominal and pelvic imaging showed anasarca but was otherwise unremarkable. A contrastenhanced CT scan of the head identified concerning areas of air within the inferior orbital fissure, retroantral space, pterygopalatine fossa, inferior turbinate, concerning for invasive fungal rhinosinusitis. An MRI of the brain later revealed a subacute infarct in the left temporal lobe. Under ENT, the patient underwent extensive surgical debridement, during which diffuse necrotic tissue with visible fungal hyphae was observed. Although surgical fungal cultures remained negative a week later, mucormycosis can be difficult to grow from tissue cultures as the organism is a non septate fungus, and thus will die if the hyphae are disrupted. The patient received multiple retrobulbar injections of amphotericin. During his hospital stay, his leg swelling and weakness gradually improved. His leg pain responded well to gabapentin, suggesting it was secondary to diabetic neuropathy. This case illustrates the severe complications of undiagnosed LADA, including invasive fungal sinusitis and advanced neuropathy, and the value of a thorough physical exam. It underscores the need for a high index of suspicion for invasive infections in patients with acute hyperglycemia and systemic signs of infection, as timely intervention is critical to improving outcomes.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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