Case Challenge #2 Answer

Last week we presented a case of a 50 year-old woman presenting with left-sided facial pain, and a fixed and dilated left pupil. A contrast-enhanced MRI was provided and we asked you all for the next most appropriate step in management. Here’s how you answered:
Answer

And the correct answer is…

Amphotericin drip and stat neurosurgery consult

This is a case of rhinocerebral mucormycosis with concomitant cavernous sinus thrombosis. This is a life-threatening neuro-invasive fungal infection that requires prompt recognition and immediate surgical debridement and anti-fungal agents.

John Okwara wins the prize for most comprehensive explanation of the correct answer:

“The case is one of a previously healthy 50 yo F presenting with symptoms of sinusitis in the setting of a suspected URI and was treated with Dexamethasone (immunosuppressive) and Broad spectrum antibiotics (Augmentin and Levaquin). The patient is diagnosed with diabetes (clearly uncontrolled with A1c of 13). The steroids either induced this or made worse and underlying condition. After initial management, the patients symptoms of sinusitis continue to worsen significantly and we are told on exam that the patient has small black eschar in the nare (a key clue) in addition to other facial and orbital findings. The patients labs are suggestive of diabetes ketoacidosis, there does not seem to be neutropenia and the patient is HIV negative. With the risk factors of uncontrolled diabetes with ketoacidosis, recent immunosupressive agent (Dex) and broad spectrum antibiotics exposure and the exam findings especially the black eschar, this patient likely has rhinocerebral mucormycosis until proven otherwise. The MRI findings are suggestive of left cavernous sinus thrombosis which has also affected blood flow in the internal carotid arteries when compared to the right side. This vascular involvement of the cavernous sinus and internal carotid artery can be seen with rhinocerebral mucormycosis. This patient’s immediate needs are therefore immediate antifungal treatment with Amphotericin as well as surgery involvement for debridement (in this case neurosurgery).”

Congrats John! Swing by the chiefs office to collect your gift card. Stay tuned for the next case challenge.