Snapshot A 50-year-old man is brought to the emergency room via ambulance from a fire. He has extensive burns over his arms, torso, and legs. His past medical history is significant for uncontrolled diabetes. On exam, he has periorbital swelling and rhinorrhea. There is a black eschar over his nares and palate. A CT of his sinuses show air fluid levels in his maxillary and frontal sinuses. Biopsy of the black eschar reveals nonseptate hyphae branching at wide angles. Introduction Classification Mucor and Rhizopus spp. fungi with irregular, broad, and nonseptate hyphae branching at wide or right angles found in soil and decomposed material transmission via inhalation of spores or direct inoculation (through trauma) Epidemiology Risk factors ketoacidosis uncontrolled diabetes neutropenia hematologic malignancies immunocompromised status trauma burns ETIOLOGY Pathogenesis inhalation of spores causes germination in nares, sinuses, or lungs, and spread in blood vessel walls invasion into blood vessels cause hemorrhage, thrombosis, and hematogenous spread fungi can penetrate cribriform plate to enter the brain and sinuses Presentation Symptoms headache congestion facial pain sinus pressure Physical exam fevers may be only presenting symptom in immunocompromised patients with pulmonary infections soft tissue swelling black necrotic eschar on face, particularly nares or palate may affect cranial nerves blurry vision loss of ocular motility may have erythematous and necrotic papules and plaques if skin is affected Imaging Computed tomography (CT) head/sinuses indication all patients findings air-fluid levels in sinuses mucosal thickening bony destruction Studies Labs culture yield is often low and not useful Biopsy of affected tissue nonseptate hyphae with right-angle or wide-angle branching Making the diagnosis based on clinical presentation and demonstration of fungus in affected tissue high level of suspicion in patients with sinusitis-like symptoms and appropriate risk factors who do not respond to broad-spectrum antibiotics Differential Bacterial sinusitis distinguishing factor does not present with black eschar or rapid progression to brain and cranial nerves Treatment Medical amphotericin B indication first-line isavuconazole indication second-line Operative surgical debridement indications all patients in addition to antifungals Complications Death Prognosis High mortality Rapidly progressive