A 23-year-old woman with known type 1 diabetes mellitus and systemic lupus erythematosus is admitted with low-grade fever, nausea, and headache. She takes prednisone, hydroxychloroquine, and multiple daily injections of insulin. She also uses decongestants for seasonal allergies and omeprazole for acid reflux disease.
Initial laboratory results are as follows:

Lumbar puncture shows protein of 23 mg/dL and no white blood cells. Chest x-ray is normal. Urinalysis shows no evidence of infection. The patient is treated with IV fluids and insulin infusion. On the second day of hospitalization, she complains of worsening headache and blurry vision. On physical examination, she appears mildly lethargic. There is right-sided periorbital swelling and tenderness over the maxilla. There is no lymph node enlargement and the neck is supple. Chest examination is unremarkable. The abdomen is soft and nontender. There are no skin rashes.
Repeat laboratory results are as follows:

This patient would most likely require which of the following?

Question

A 23-year-old woman with known type 1 diabetes mellitus and systemic lupus erythematosus is admitted with low-grade fever, nausea, and headache.  She takes prednisone, hydroxychloroquine, and multiple daily injections of insulin.  She also uses decongestants for seasonal allergies and omeprazole for acid reflux disease.
Initial laboratory results are as follows:

Lumbar puncture shows protein of 23 mg/dL and no white blood cells.  Chest x-ray is normal.  Urinalysis shows no evidence of infection.  The patient is treated with IV fluids and insulin infusion.  On the second day of hospitalization, she complains of worsening headache and blurry vision.  On physical examination, she appears mildly lethargic.  There is right-sided periorbital swelling and tenderness over the maxilla.  There is no lymph node enlargement and the neck is supple.  Chest examination is unremarkable.  The abdomen is soft and nontender.  There are no skin rashes.
Repeat laboratory results are as follows:

This patient would most likely require which of the following?

Quizplus · Accepted Answer

11ec193a_96fe_a0e1_853d_9dabe406909b_MD0002_00 This immunocompromised patient with diabetic ketoacidosis most likely developed rhino-orbital-cerebral mucormycosis, a devastating mold infection. The Mucorales species (eg, Rhizopus, Mucor, and Rhizomucor) are the most common pathogens found in soil and decaying vegetable matter. These organisms thrive in high-glucose, acidic conditions. Angioinvasion leading to tissue infarction is the hallmark of mucormycosis. Infection usually begins in the nasal turbinates through spore inhalation and presents with acute sinusitis (eg, fever, sinus pain, purulent nasal discharge, and congestion). The disease usually progresses rapidly, as patients develop symptoms due to invasion of the eye structures and brain. Imaging may reveal edematous mucosa and destruction of facial bone and periorbital tissues. Diagnosis is made by biopsy and tissue examination that show hyphae with irregular branching without septations. Aspergillus also affects immunocompromised patients; it has hyphae with regular branching and many septations. Treatment includes immediate, thorough surgical debridement and IV amphotericin B. (Choice A) Gram-negative rod infections (eg, Pseudomonas aeruginosa) are common in diabetics. They usually cause skin and soft-tissue infections instead of the combined sinus and periorbital disease seen in this patient. (Choice B) MRI would be less useful in this patient, who has a supple neck, normal lumbar puncture results, and no evidence of invasion into the soft tissues of the neck or carotid artery (eg, acute motor or sensory deficits). (Choice C) Although this patient has slightly altered mentation, the initial lumbar puncture showing no WBCs makes meningitis unlikely. A repeat lumbar puncture would therefore be less useful. (Choice E) Cardiac mucormycosis is extremely rare, and transesophageal echocardiography would not be useful in the management of rhino-orbital-cerebral mucormycosis. Infective endocarditis is unlikely in this patient. Educational objective: Rhino-orbital-cerebral mucormycosis is an uncommon but devastating infection in diabetic patients with poor glucose control and frequent episodes of ketoacidosis. Diagnosis is made by histology and culture revealing irregular branching hyphae without septations. Surgical intervention combined with IV amphotericin B is needed to achieve cure. __________ References: Epidemiology and clinical manifestations of mucormycosis (http://www.ncbi.nlm.nih.gov/pubmed/22247442) Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment (http://www.ncbi.nlm.nih.gov/pubmed/14748801)

A 23-Year-Old Woman with Known Type 1 Diabetes Mellitus and Systemic