Published on June 27, 2014
Case 1 50 yr male Background: Poorly controlled DM-type 2 (HbA1c- 12.8) Presents to ED with a 2 day H/O high fever, headache & Rt sided Facial swelling. Noted to be septic with pyrexia, hypotension & tachycardia. CBGs were persistently >500.
Clinical Examination Pyrexial Dehydrated Pale Tender maxillary & frontal sinuses. Chest & Abdominal examination grossly normal.
Investigations TC- 33780; 93% Neutrophils Hb – 4.8 Cr- 3.9 CRP- 217 CXR- clear ABG – Not Acidotic, Urinary Ketones Absent ESR-15 CoCa-7.5 Iron studies- Ferritin- 2354, Se Fe- 20, TIBC- 180 ANA, ANCA negative Serum Electrophoresis- No Monoclonal Bands. USS Abd- Mild Hepatomegaly Blood cultures & Urine cultures sent. Nasal Scrapping sent.
Pt was consented before taking these photographs
CT scan of Sinuses & orbit
Management IVF & Intravenous Insulin infusion Meropenem & Teicoplanin AntiFungal cover initially with Iatraconazole. DVT Prophylaxis Ophthalmologic Evaluation suggested orbital cellulites secondary to maxillary sinusitis.
The ENT team reviewed the patient, Flexible nasal endoscopy done which revealed RT Maxillary sinus mucosal thickening. FESS & Endoscopic clearance of the RT nasal cavity was performed. OT note- Blackish pultaceous material was noted in the RT nostril highly suggestive of Fungal Rhino sinusitis. Debridement of the Frontal, Maxillary & Ethmoidal sinuses were performed. Tissue sent for HPE. Anterior & Posterior Ethmoidectomy done
Post operative Management Based on the Macroscopic findings during OT pt was started on aggressive Antifungal Therapy Posaconazole- 200mg TDS (Amphotericin B initially not considered as pt had Diabetes related CKD) Pt was also started on Iron Chelation therapy with Deferiprone 1500mg TDS.
HPE of sinus
Branching Aseptate HyPhae
The Patient continued to remain unwell c/o persistent headache, Lt sided weakness & Rt eye pain. TC & CRP were still high 13200 (33780) & 124(217). ENT evaluation revealed recurrent crusting & a repeat FESS was advised. However we did a repeat MRI, to asses disease spread.
Repeat MRI Brain revealed
Aggressive AntiFungal Therapy Amphotericin B lipid complex was started dose 3-5mg/kg. Posaconazole stopped. Iron chelation is being continued. Dramatic response to therapy, headache now completely resolved, RT swelling improved.
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