A 46-year-old hospitalized man is evaluated for 1 day of fever, dull facial pain, and nasal discharge. The patient was admitted to the intensive care unit 3 days ago for diabetic ketoacidosis. He has a history of poorly controlled type 1 diabetes mellitus due to medication noncompliance and has had multiple hospitalizations for ketoacidosis. He does not use tobacco or alcohol. He has no known drug allergies. Temperature is 38.5 C (101.3 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 16/min. Foul-smelling discharge is present in the right naris, and nasal examination shows a necrotic right nasal turbinate. Cardiopulmonary examination is normal. Morning laboratory studies show resolution of the ketoacidosis and a hemoglobin A1c of 8.5%. Potassium hydroxide stains of scrapings from the nasal turbinates reveal hyphae. Which of the following is the best next step in the management of this patient?

Question

A 46-year-old hospitalized man is evaluated for 1 day of fever, dull facial pain, and nasal discharge.  The patient was admitted to the intensive care unit 3 days ago for diabetic ketoacidosis.  He has a history of poorly controlled type 1 diabetes mellitus due to medication noncompliance and has had multiple hospitalizations for ketoacidosis.  He does not use tobacco or alcohol.  He has no known drug allergies.  Temperature is 38.5 C (101.3 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 16/min.  Foul-smelling discharge is present in the right naris, and nasal examination shows a necrotic right nasal turbinate.  Cardiopulmonary examination is normal.  Morning laboratory studies show resolution of the ketoacidosis and a hemoglobin A1c of 8.5%.  Potassium hydroxide stains of scrapings from the nasal turbinates reveal hyphae.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d463_7fbd_bc81_0bbdeb40f6cb_MD0003_00 Mucormycosis is an invasive fungal infection caused by a collection of molds (eg, Rhizopus, Mucor) 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. hyphae Rhino-orbital-cerebral mucormycosis is the most common manifestation. Symptoms occur acutely 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. Diagnosis requires sinus endoscopy with biopsy (histopathologic identification of organism) and culture. Mucormycosis is angioinvasive and rapidly fatal. Treatment involves aggressive surgical debridement of necrotic tissue, antifungal medications (eg, liposomal amphotericin B), and elimination of contributing risk factors (eg, hyperglycemia, ketoacidosis). (Choice A) Hyperbaric oxygen is sometimes used for mucormycosis, but data is lacking. Surgical debridement is required to eliminate the necrotic tissue. (Choices B, D, and E) Fluconazole and voriconazole are not effective treatments for mucormycosis. In patients with hematologic malignancy, voriconazole is an independent risk factor for developing mucormycosis. Educational objective: Mucormycosis is an invasive fungal infection most commonly seen in patients with poorly controlled diabetes mellitus (especially in ketoacidosis). Treatment involves surgical debridement, antifungal medication (eg, liposomal amphotericin B), and the elimination of promoting factors (eg, hyperglycemia, ketoacidosis).

A 46-Year-Old Hospitalized Man Is Evaluated for 1 Day of Fever