A 22-year-old hospitalized man is evaluated for new-onset fever. The patient has a history of type 1 diabetes mellitus and came to the hospital 4 days ago due to abdominal pain, nausea, and vomiting. Admission laboratory studies showed blood glucose of 450 mg/dL, positive urine ketones, and metabolic acidosis on arterial blood gas analysis. He was treated with intravenous fluids and insulin infusion with improvement in his condition, and was transitioned to subcutaneous insulin. Over the past 24 hours, he has had high fever, worsening headache, and nasal congestion. Temperature is 38.9 C (102 F), blood pressure is 130/80 mm Hg, and pulse is 110/min. Mild periorbital swelling is present. There is right-sided, bloody, purulent nasal discharge and a black eschar on the inferior nasal turbinate. Percussion reveals a tender right-sided maxillary sinus. Neurological examination is normal. Which of the following is the best pharmacological treatment for this patient's current condition?

Question

A 22-year-old hospitalized man is evaluated for new-onset fever.  The patient has a history of type 1 diabetes mellitus and came to the hospital 4 days ago due to abdominal pain, nausea, and vomiting.  Admission laboratory studies showed blood glucose of 450 mg/dL, positive urine ketones, and metabolic acidosis on arterial blood gas analysis.  He was treated with intravenous fluids and insulin infusion with improvement in his condition, and was transitioned to subcutaneous insulin.  Over the past 24 hours, he has had high fever, worsening headache, and nasal congestion.  Temperature is 38.9 C (102 F), blood pressure is 130/80 mm Hg, and pulse is 110/min.  Mild periorbital swelling is present.  There is right-sided, bloody, purulent nasal discharge and a black eschar on the inferior nasal turbinate.  Percussion reveals a tender right-sided maxillary sinus.  Neurological examination is normal.  Which of the following is the best pharmacological treatment for this patient's current condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfb0_acbe_8f63_e74db3752181_MD0005_00 This patient with diabetic ketoacidosis developed fever, periorbital swelling, and a necrotic nasal turbinate, raising suspicion for rhino-orbital-cerebral mucormycosis. Rhino-orbital-cerebral mucormycosis is most commonly due to the ubiquitous fungus Rhizopus oryzae. This organism possesses an enzyme (ketone reductase) that catalyzes growth in high-glucose, acidic environments. As such, >70% of patients with mucormycosis have underlying diabetes mellitus, most often with ketoacidosis. Manifestations include fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread to the palate, orbit, and brain is common. Sinus endoscopy is required for both diagnosis (biopsy and culture) and treatment (surgical debridement). Patients also require the prompt initiation of intravenous liposomal amphotericin B. Once clinically improved, amphotericin B can be transitioned to several weeks of step-down therapy with oral antifungal medication (eg, posaconazole). (Choice A) High-dose penicillin can treat cervicofacial Actinomyces infection, which usually manifests as a slow-growing, painless mass near the jaw with multiple draining sinus tracts. (Choice B) Caspofungin is often used to treat invasive candidiasis. Invasive candidiasis usually manifests with systemic symptoms and may affect a large number of organs, including the eyes (chorioretinitis) and skin. This patient with diabetic ketoacidosis and acute, rapidly progressive, necrotic rhinosinusitis is more likely to have mucormycosis. (Choice C) Aspergillosis is often treated with intravenous voriconazole and may occasionally present with a clinical profile similar to that of rhino-orbital mucormycosis; however, patients are typically neutropenic, not diabetic. (Choice E) Trimethoprim-sulfamethoxazole is often used to treat nocardiosis, which typically causes pulmonary or central nervous system (eg, brain abscess) disease. Sinus disease is quite rare. Trimethoprim-sulfamethoxazole is not an effective treatment for mucormycosis. Educational objective: Rhinocerebral mucormycosis is most commonly seen in patients with diabetic ketoacidosis. Treatment requires surgical debridement and intravenous liposomal amphotericin B.

A 22-Year-Old Hospitalized Man Is Evaluated for New-Onset Fever