History
62 year old female presents with 2 weeks of clear watery discharge from the left eye and painless erythema between the left eye and nose. Endorses nasal congestion bilaterally. Denies fevers/chills, headache, sinus pain, cough, shortness of breath, malaise, fatigue, nausea/vomiting, vision changes or other symptoms.
Past medical / surgical history
Renal transplant, hypertension, hyperlipidemia, diabetes, cerebrovascular accident, coronary artery disease, nasal sinus abscess (pseudomonal growth) status post incision and drainage 3 months prior, COVID-19 infection 4 weeks prior
Allergies: seasonal
Medications: many to include tacrolimus, mycophenolate, insulin
Physical Exam
Vitals: Temperature 36.5 C, HR 66, RR 18, BP 120/64, SpO2 98% on RA
General: Alert, no acute distress, nontoxic appearing
Skin: 2cm diameter, nontender, erythematous area between left eye and nose. No fluctuance or swelling noted.
Eye: extraocular movements intact, visual acuity intact, PERLLA, Normal conjunctiva
ENT: Oral mucosa moist
Cardiovascular: regular rate and rhythm. No murmur, rubs, gallops. No peripheral edema.
Respiratory: Clear to auscultation bilaterally. Equal chest rise.
GI: Soft, nontender, nondistended
Neurological: A&O x3, no focal neurologic deficits observed
Differential
Covid 19
Viral illness
Seasonal allergies
conjunctivitis
cellulitis
recurrent abscess
something else?
Laboratory findings
**abnormal labs similar to prior visits
Radiographic Findings
CT face and sinuses, non-contrasted
Impression:
Evaluation for abscess is limited without intravenous contrast.
Significant opacity within the paranasal sinuses with osseous dehiscence of the left lamina papyracea, medial maxillary sinus walls and hard palate.
Infiltration and likely spread of infection to involve the extraconal medial left orbit, left pterygopalatine fossa and left retro antral fat.
Recommend further evaluation with MRI of the brain and sinuses with and without contrast and clinical correlation for acute invasive fungal sinusitis.
ED Clinical Course
Clinical condition stable, zosyn given
Transplant, ENT, ophthalmology consulted
ENT nasopharyngeal endoscopy revealed black discolored tissue, biopsy obtained in ED.
Patient admitted to medicine
Hospital Clinical Course
Inpatient MRI Brain and Sinuses with and without contrast
IMPRESSION:
Acute invasive fungal pansinusitis involving the left medial orbital wall, pterygopalatine fossa extending to the sphenopalatine foramen and pterygomaxillary fissure, and left masticator space as described above. Questionable involvement of the left orbital apex. No evidence of intracranial extension. No intracranial abscess at this time.
Infectious disease consulted, recommended amphotericin B, vancomycin, cefepime, metronidazole pending biopsy results.
ENT planning OR for debridement
-Course to be continued
Mucormycosis
Presentation
Acute sinusitis with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. All sinuses become involved, spread to contiguous structures to include the palate, orbit, and brain. Usually progresses rapidly over the course of days.
Fever - 44%
Nasal ulceration and/or necrosis - 38%
Periorbital or facial swelling - 34%
Decreased vision - 30%
Sinusitis - 26%
Ophthalmoplegia - 29%
Headache - 25%
Risk factors
Diabetes mellitus, particularly DKA
Glucocorticoid usage
Hematologic malignancies
Hematopoietic cell transplantation
Solid organ transplantation
Recent COVID19 infection
AIDS
IV drug use
Trauma / burns
Malnutrition
Iron Overload
References
Ravindra, K., & Ahlawat, A. (2021). Five probable factors responsible for the COVID-associated mucormycosis outbreak in India. International Journal of Infectious Diseases, 112, 278-280.
https://www.rstmh.org/news-blog/blogs/mucormycosis-epidemic-another-dark-side-to-the-covid-19-pandemic
David Rapoport, MD