Ketoacidosis, Diabetes and pneumonia

A 35-year-old woman previously healthy went to the Emergency Department (ED) with obnubilation and dehydratation without fever. A blood test showed a glucose level  over 550 mg with Ketoacidosis. After 48 hour treatment she was discarded home with insulin and a GP appointment. Final Diagnosis: Diabetes de novo.

A week later she went back to the ED with fever and a productive cough. The glucose level was under control but a consolidation was detected at the basal right lobe. She was sent home with antibiotics. Final Diagnosis: community  acquired pneumonia.

But she was not a “normal” patient

Here we present two X-ray from the first and the second visit with one-week of difference.

What´s your election as the etiological agent?

FINAL DIAGNOSIS: mucormycosis pneumonia

ANALYSIS: Representation heuristic is a shorcut to select a diagnosis based on aspects of a clinical situation that “trigger” the recognition of pattern of a pathological entity inside doctor´s brain. The clinician framework of pattern recognition is based on the prevalence of a disease or syndrome in the usual clinical environment. However,people with some particular diseases or conditions (like a person with diabetes and ketoacydosis) can be more prone to diseases with a low prevalence in the general population but a higher incidence in a particular group. In this case “COMMUNITY ACQUIRED PNEUMONIA” was a good diagnosis for a person coming to the hospital with a consolidation and no previous disease, In our case the recent diabetes and ketoacydosis increase significantly the risk of a uncommon pneumonia.

COMMENTS : Prevalence is not a fix value and it is influenced by special conditions, drugs or associated diseases. Ketoacydosis or depheroxamine treatment increase the risk of mucormycosis pneumonia.

Mechanisms of a disease is important to help to think in an uncommon clinical entity. Mucormycosis is a fungus with a special “appetite” for iron and in a situation of ketoacydosis is easier to get it.