Transcript Teaching Case of the Week - McMaster Faculty of Health

Teaching Case of the Week
Dr. W. A. Ciccotelli
Sept 14, 2005
The Patient
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82 y M
Past Hx
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Low grade B cell lymphoma
Pancytopenia/transfusion dependent
Interstitial lung dz
HTN
Ex-smoker
The Patient
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Meds
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Amlodipine
Prednisone (taperingx 4 mos)
NKDA
2-4x EtOH/wk
The Case
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Referred to ID for peri-orbital cellulitis
3 day Hx of progressive
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R eye swelling
R frontal headache
Reactive clear discharge
FB sensation
No fever/chills
No other ocular symptoms
Vision ok
On cefotaxime 36 hrs
The Case
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Afebrile, VSS
Peri-orbital cellulitis
R eye proptosis, mild ptosis, chemosis
Loss of EOM R eye
CNs normal otherwise
Visual acuity normal
The Case
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WBC 4.9, Hgb 99, plts 54, grans 1.7
Lytes N
Cr 123
TSH 1.1
Panculture neg
CXR: unchanged chronic interstitial
pattern
The Case
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CT scan head
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R pre-septal edema
Minimal proptosis R eye
R Maxillary & ethmoidal sinusitis
R nasal septum deviation
No bony lesions
No retro-orbital masses
ENT consulted
The Case
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Not responding on Cefotaxime
Febrile
New diplopia
Worsening peri-orbital cellulitis
The Case
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Abx changed to Clinda/Cipro
MRI head
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Small fluid collection lat. R eye ?abscess
Maxillary & ethmoid sinusitis (L & R)
Meninges inflammatory changes in R middle
cranial fossa
No cavernous vein thrombosis
Nasal culture: commensal flora
The Case
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Now really bad!
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Delirious
Febrile
Clonus in lower ext.
R Facial droop
The Case
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Urgent ethmoidectomy
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necrotic sinus
painless procedure
LP aseptic meningitis
ANCAs neg
Lipo Ampho B started 5 mg/kg/day
The Case
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Repeat MRI
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Early cerebritis R temporal operculum
Ongoing inflammatory changes of all sinuses
Inflammatory changes around R orbit,
masticator space, cavernous sinus
Case Resolution
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Further CNS deterioration
Sinus Bx
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Broad ribbon like non-septate fungal filament on
microscopy
ZN & PAS stains confirm non-septate hyphae
Dx of Rhinocerebral zygomycosis
Lipo Ampho B to 10 mg/kg/day
Family withdrew care given degree of surgery
needed
Zygomycosis
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Mucorales order
Ubiquitous in environment
Thick walled non-septate hyphae with right
angle branching
Rare & mimics other invasive mould infections
Inherent resistance to antifungal agents
Angioinvasive disease
Zygomycosis
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Multiple clinical forms
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Cutaneous
Pulmonary
Gastrointestinal
Rhinocerebral
Sino-orbital
Disseminated
Direct inoculation, inhalation, ingestion of spores
Zygomycosis
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Immunocompromised state hallmarks
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DM ketoacidosis
Neutropenia
Chemotherapy
BMT patients
Lymphoma/leukemia
Trauma with exposure to contaminated soil
Zygomycosis
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Dx is difficult & delayed
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Poor recovery from culture
Non specific presentation
Not on everyone’s DDx
Mimics other invasive molds (Aspergillus)
Dx generally made with invasive testing for
histopathological sampling
Dx commonly made at autopsy
Yet increasingly problematic in Heme-Onc
patients over 1990s
Zygomycosis
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Treatment is multifaceted
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Immune reconstitution
Aggressive surgical debridement
Ampho B
Prayer
Posaconazole as oral alternative
Despite this still highly fatal (mortality 5080%)
Zygomycosis
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Prognosis is poor
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Late Dx
Not able to recover immune system
Disseminated
Death usually from hemorrhage
Best prognosis
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Limited disease
Early surgery
Non Heme-Onc patients
Zygomycosis
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Tip offs
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Right patient population (esp neutropenia)
Unexplained thrombosis
Necrotic eschar
Unexplained hemorrhage
Common clinical situations
Culture neg despite real disease
 Not responsing to reasonable Abx
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