A 73-year-old man comes to the office due to 3 days of fever, facial pain over his right cheek, and bloody nasal discharge. Last night he was able to see without difficulty, but this morning, he developed double vision. He has had no recent trauma to the face or dental procedures. The patient has a 30-year history of type 2 diabetes mellitus complicated by nephropathy and retinopathy. His medical history also includes hypertension and hyperlipidemia. He is widowed and lives alone. He does not use tobacco or alcohol. Temperature is 39 C (102.2 F), blood pressure is 130/76 mm Hg, and pulse is 102/min. The patient appears ill. Chemosis and mild proptosis of the right eye are present. There is tenderness over the right maxillary sinus. Nasal examination shows right nasal congestion and necrosis of the right nasal turbinate. Necrosis of the hard palate is present. Cardiopulmonary examination is normal. The patient has no skin rash. CT scan reveals opacification and bony erosion of the right maxillary sinus. Hemoglobin A1c is 11%. Which of the following is the most likely causative organism?

Question

A 73-year-old man comes to the office due to 3 days of fever, facial pain over his right cheek, and bloody nasal discharge.  Last night he was able to see without difficulty, but this morning, he developed double vision.  He has had no recent trauma to the face or dental procedures.  The patient has a 30-year history of type 2 diabetes mellitus complicated by nephropathy and retinopathy.  His medical history also includes hypertension and hyperlipidemia.  He is widowed and lives alone.  He does not use tobacco or alcohol.  Temperature is 39 C (102.2 F), blood pressure is 130/76 mm Hg, and pulse is 102/min.  The patient appears ill.  Chemosis and mild proptosis of the right eye are present.  There is tenderness over the right maxillary sinus.  Nasal examination shows right nasal congestion and necrosis of the right nasal turbinate.  Necrosis of the hard palate is present.  Cardiopulmonary examination is normal.  The patient has no skin rash.  CT scan reveals opacification and bony erosion of the right maxillary sinus.  Hemoglobin A1c is 11%.  Which of the following is the most likely causative organism?

Quizplus · Accepted Answer

11ec25c8_d0e9_c23a_bc81_bb60f10b0187_MD0003_00 Mucormycosis is a highly destructive fungal infection caused by a collection of molds ubiquitous in the environment. Spores are inhaled and convert to hyphae in the nasal turbinates and respiratory tree. Immunocompetent individuals rapidly clear the organism, but individuals with significant immunocompromise are at high risk for invasive disease. Patients with poorly controlled diabetes mellitus (especially with ketoacidosis) are most likely to develop mucormycosis. Rhino-orbital-cerebral mucormycosis is usually caused by Rhizopus species. Symptoms are acute and include fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread (due to infarction of infected tissues) to the palate, orbit, and brain is common. Early diagnosis is critical as mortality rates are as high as 60%; any patient with significant immunocompromise and sinusitis requires sinus endoscopy with cultures and biopsy (histopathologic identification of the organism) to evaluate for mucormycosis. Treatment involves surgical debridement, antifungal therapy (eg, liposomal amphotericin B), and elimination of the predisposing factor (eg, hyperglycemia). organism (Choice A) Actinomyces is a commensal bacterium of the oral cavity that may cause a painless, slow-growing mass with draining sinus tracts (sulfur granules) on or near the jaw. Infections occur mainly in patients with immunocompromise (eg, diabetes mellitus) after dental procedures. This patient has an acute, painful infection with prominent necrosis, making mucormycosis more likely. (Choice B) Clostridium septicum causes spontaneous gas gangrene with acute fever, severe muscle pain, and bullous, taut skin lesions. Infections primarily involve the extremities. (Choice C) Oral anaerobic bacteria are less likely to cause disease in the aerobic sinus environment. This patient with poorly controlled diabetes mellitus, palate/turbinate necrosis, and sinus drainage likely has mucormycosis. (Choice D) Pseudomonas aeruginosa is an aerobic gram-negative organism that can cause a variety of infections, including endophthalmitis. This infection usually manifests with acute ocular pain and decreased visual acuity after eye trauma or surgery. Palate/turbinate necrosis and nasal discharge are atypical. (Choices F and G) Staphylococcus aureus and Streptococcus pneumoniae are common causes of bacterial sinusitis. Severe cases may result in complications, including osteomyelitis; however, symptoms typically arise over days or weeks and would not be associated with necrosis of the hard palate and turbinate. Educational objective: Mucormycosis is an invasive fungal infection that most commonly manifests as rhino-orbital-cerebral disease in patients with immunocompromise (particularly poorly controlled diabetes mellitus). Symptoms include acute fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread is common. Diagnosis requires sinus endoscopy with tissue sampling. Rhizopus is the most common cause.

A 73-Year-Old Man Comes to the Office Due to 3