Male patient, 33 years old, with a history of chronic end-stage renal failure secondary to polycystic disease. He was transplanted from a deceased donor at another institution in 2007. He received immunosuppressive treatment with prednisone, tacrolimus and mycophenolate mofetil. In March 2012 he underwent a renal biopsy that reported acute cellular rejection Banff IA. He received treatment with methylprednisolone 1500 mg, prednisone 50 mg per day, mycophenolate 3000 mg per day and tacrolimus XL 7 mg per day. One month later, the patient presented with fever, frontal and retro-ocular headache, with decreased sensitivity in the right hemiface. He was evaluated and diagnosed with acute sinusitis and was started on treatment with amoxicillin. The patient did not improve and began to present ocular proptosis, oedema of the right upper jaw, greenish rhinorrhoea, diplopia, epiphora, ulcer in the palate, convulsions and azotemia. For this reason he was referred to our institution. On admission he was feverish, with oedema in the right hemicara, extensive ulcer on the hard palate, ocular proptosis, ophthalmoplegia, loss of vision in the right eye and altered renal function. Magnetic resonance imaging of the brain showed involvement of the paranasal sinuses, right orbit, frontal lobe, cavernous sinuses, right basal ganglia and ipsilateral area of the thalamus. With these findings, a diagnosis of MROC was made, so liposomal amphotericin B was started, immunosuppression was suspended and the patient underwent radical multidisciplinary surgery, where sinusitis drainage, drainage of the right frontal brain abscess, extensive resection of the soft and bony tissues of the right hemiface, enucleation, tracheostomy and gastrostomy were performed. Cultures and pathology confirmed Mucor infection. Additionally E. cloacae, C. sedlakii, K pneumoniae BLEE (β-lactamase extended spectrum enzyme-lactamase) positive were isolated.

A magnetic resonance imaging check still shows involvement of the disease in the brain. However, given the extent and serious sequelae of more radical surgery, it was decided to continue medical management. For this reason, treatment was completed for 6 weeks after radical surgery with liposomal amphotericin B, meropenem, linezolid and posaconazole plus twice-weekly dressings. Subsequently he was discharged with posaconazole 400 mg every 12 hours, cyclosporine 50 mg every 12 hours, prednisone 5 mg daily and nutrition by gastrostomy. Six months later the patient was in good general condition, with no signs of active infection and with acceptable renal graft function (creatinine 1.5 mg/dl). He underwent successful surgical reconstruction. Six months after reconstruction the patient is in good general condition and is currently planning to complete his facial reconstruction process.