most of the dual infections cause a diagnostic dilemma and require a high degree of suspicion in susceptible individuals .
however , dual infections with mucormycosis may follow a fulminant course and may be associated with higher mortality and morbidity .
we hereby report coinfection of pulmonary tuberculosis ( tb ) with mucormycosis in a diabetic male that worsened rapidly in spite of the antimicrobial therapy targeted toward the same .
a 72-year - old nonsmoker male , known case of diabetes mellitus type ii since 10 years , on oral hypoglycemic agents , presented with the complaints of altered sensorium with low - grade fever associated with pain abdomen and vomiting and was diagnosed to have severe urinary tract infection .
he was being managed in the ward for diabetic ketoacidosis for the same and was doing well until the 9 day of admission when he developed cough , expectoration , and difficulty in breathing .
subsequently , the patient was intubated and transferred to intensive care unit ( icu ) for mechanical ventilation with synchronized intermittent mandatory ventilation mode and further managed according to the institutional protocol .
all routine biochemical and hematological investigations including the chest x - ray ( cxr ) were sent .
blood sugar levels were found to be 460 mg% and total lymphocyte count was 1200 mm , and urine ketones were found to be positive .
arterial blood gas on the day of admission at fio2 of 0.6 had a pao2/fio2(pf ) ratio of 261 . empirical antibiotic therapy and vasopressor
support with noradrenaline ( 0.5 g / kg / min ) was started as per protocol .
sputum examination undertaken in the ward itself was negative for acid fast - bacilli ( afb ) .
the cxr showed bilateral cavitary lesions in all the zones on the very 1 day of icu admission . with a high index of suspicion for fungal pneumonia based on the clinical and radiological findings and negative sputum for afb , antifungal ( caspofungin 70 mg intravenous [ iv ] loading dose followed by 50 mg iv once daily )
however , no clinical improvement was noticed over 5 days , and radiological deterioration was evident by the appearance of new cavitary lesions developing over every 24 h [ figure 1 ] .
the pf ratio also started deteriorating consistently with the values of 161 on the 3 day falling to 114.5 on the 9 day with fio2 going up to 0.9 .
with patient condition deteriorating as evidenced by higher ionotropic support and decreasing pf ratio , bronchoalveolar lavage ( bal ) was performed , and wastings were sent for afb staining , pyogenic culture , and fungal culture .
subsequently , antitubercular treatment was also initiated as per the revised national tuberculosis control program guidelines for the same .
although the potassium hydroxide wet mount revealed no fungal elements , fungal culture showed growth of rhizopus species on the 2 day of inoculation [ figure 2 ] , following which amphotericin b ( in the dose of 0.5 mg / kg iv loading dose followed by 1 mg / kg once daily ) was introduced as per culture sensitivity . on the 11 day , the pf ratio had further fallen to 71 on fio2 of 1.0 .
however , the patient failed to improve and succumbed on the 12 day of admission to icu . multiple cavitatory lesions on day 5 lactophenol cotton blue mount showing rhizopus microsporus species ( lcb 200 )
opportunistic fungal organisms such as candida species , aspergillus species , mucor species , and cryptococcus neoformans may be encountered in diabetic patients who are usually immunocompromised by virtue of the disease itself .
diabetes mellitus may predispose to mucormycosis in 3688% of patients which is a serious , potentially fatal fungal infection that needs a high degree of suspicion for the diagnosis .
patients with uncontrolled hyperglycemia , particularly those with ketoacidosis , are the most susceptible and it may be the first manifestation in patients with undiagnosed diabetes mellitus .
the most common presentation is rhino - orbital - cerebral involvement followed by pulmonary infection .
patients with diabetes are prone to develop tb and have high chances of treatment failure .
a large proportion of people with diabetes further developing tb are not diagnosed , or diagnosed too late , may be due to lack of awareness on the part of the patient to report early for any development of chest symptoms .
coinfection with pulmonary tb and mucormycosis in immunocompromised patients may present a diagnostic dilemma owing to similar clinical presentation and need a high degree of clinical suspicion and early aggressive treatment . both clinical entities
in addition , the radiological features of consolidation , cavitation , infiltrates , and effusion are common to both the diseases and , therefore , histopathological examination or culture sensitivity should be undertaken at the earliest to make definitive diagnosis .
it is possible that the high relapse cases , treatment failures , resistance , and high mortality associated with tb infection are partly attributed to coinfection with opportunistic fungal pathogens and drug - resistant non - tb bacteria . in the present case , an immunocompromised state prevailing as a result of diabetes and tb made the patient prone to acquire coinfection with mucormycosis .
although cavitation was evidenced on the very 1 day of admission to icu , negative sputum examination in the ward made tb an unlikely diagnosis .
however , conclusive diagnosis was made only after bal which demonstrated the presence of afb on smear and ubiquitous filamentous fungus rhizopus species , of mucorale order , colonization on culture .
there are isolated reports of coinfection of mucormycosis and tb in immunocompromised patient where the patients were successfully treated . in the present case
, the unfavorable outcome may be the result of delayed diagnosis which was probably missed for the first 8 days in a ward where primarily the focus was on treating diabetic ketoacidosis .
meanwhile , the hyperglycemic environment that favors immune dysfunction ( e.g. , damage to the neutrophil function , depression of the antioxidant system , and humoral immunity ) flared up coinfection of mucormycosis with latent tb progressing to active tb and followed a fulminant course .
latent tb and drug - resistant tb in patient with diabetes make them susceptible to opportunistic infections with potentially fatal fungal infections . simultaneous infection with mycobacterium tuberculosis and mucormycosis is a rare finding and requires high clinical vigilance .
now - a  days , it is imperative to consider fungal infections as an important differential diagnosis .
early and aggressive treatment targeting the isolated organisms may help reduce the mortality and morbidity .
meanwhile , screening the patients with diabetes for coinfections , especially in nonresolving pneumonias are imperative and should be practiced in a protocolized form in early stages of diabetes .
 herein , we present the case report of an adult male diabetic patient who had coinfection with mycobacterium tuberculosis and mucormycosis , which otherwise is a rare clinical entity . 
 diabetes mellitus may predispose a patient to tuberculosis ( tb ) infection which further weakens immune system thus making him susceptible to other fungal or bacterial infections which may pose various treatment difficulties . therefore , there is a need for mycological and bacteriological investigations in patients with pulmonary tb to rule out secondary coinfections thus contributing to better management . 
Introduction
Case Report
Discussion
Conclusion
None
Financial support and sponsorship
Conflicts of interest