Mucormycosis

Case #365: Maxillo-Facial CT, 2/25/95, & MRI brain, 2/26/95: Mucormycosis with left frontal sinus bony dehiscence seen on CT; with extension of disease on to dura seen on MRI

 

CC: Headache.

 

63y/o caucasian male presented on transfer from a local hospital for a 3 week history of frontal headache(left worse than right) and paranasal sinus disease unresponsive to Augmentin. He denied diplopia, dysarthria, dysphagia, ageusia, anosmia, vision obscuration, facial or other weakness/numbness, fever, chills, epistaxis or purulent nasal discharge. He has had no photophobia, phonophobia, nausea or vomiting associated with his headaches. The headache has been constant and dull-pressure in character. There has been no weight loss or anorexia.

 

MEDS: Humulin NPH 17-0-10units, Humulin regular 8-0-5units, ASA qd, Niferex, Prazosin, Ranitidine, MVI qd, Florinef 0.1mg qd, CaCO3, Augmentin 250 TID x 7 days.

PMH: 1)DMII with end stage renal disease( placed on hemodialysis 9/93), peripheral neuropathy, 2)Peripheral Vascular disease, 3) CAD with inferior wall MI 9/92, 4)Tonsillectomy, 5)appendectomy, 6)MRSA infection right foot, 1987, 7)Stroke, 1991(unknown type), 8)HTN, 9)Orthostatic hypotension.

FHx: noncontributory.

SHx Married, 2 children, Denied ETOH/Tobacco/illicit drug use.

 

EXAM(per Medicine and Otolaryngology notes): BP131/74, HR89, RR20, 36.0C

The neurologic exam was unremarkable except for decreased PP/VIB sense in stocking type distribution from the toes to the knees in BLE.

HEENT: unremarkable with no lymphadenopathy.

Gen Exam: unremarkable except for trace BLE edema.

 

COURSE: Serum WBC 11,800. Outside Sinus CT, 2/17/95, was reviewed and showed evidence of paranasal sinus disease and pneumocephalus. The patient was placed on clindamycin IV and repeat Sinus CT was obtained, 2/25/95. This showed severe paranasal sinus disease with bony dehiscence of the postero-lateral aspect of the left frontal sinus. An MRI brain, 2/26/95, showed left frontal and ethmoid sinus disease. There was a 2x1cm ring enhancing lesion posterior to the left fronta sinus consistent with abscess. This was accompanied by thickening and enhancement of the adjacent dura. There was evidence of an old hemorrhage in the left caudate and adjacent white matter disease. He underwent ethmoidectomy, sphenoidectomy, and obliteration of the left frontal sinus. on 2/27/95. There was a small bony dehiscence of the left posterior table, but no clear evidence of osteomyelitis. Pathologic analysis revealed broad non-septate hyphae with right angle branching consistent with mucor.

Postoperatively an EKG revealed pronounced ST-segment depression in and mild ST-segment elevatons. He ruled out for MI with negative serial cardiac enzymes. He was immediately placed on Amphotericin. Cultures for the sinus obliteration later grew many species of Pseudomonas aeruginosa and he was placed on ceftazidime and tobramycin. On 3/2/95 he went to the SICU for hypotension of 85/40 and a decline in mental status. MRI on 3/1/95 revealed an ring enhancing area anterior to the left frontal lobe with effacement/edema of the left fronatal lobe sulci suggestive of epidural abscess with breakthrough leading to cerebritis of the left frontal lobe. Neurology wasconsulted and concluded his mental decline was multifactorial. On 3/21/95, he became unresponsive, bradycardic and hypotensive with systolic pressures down to 65mmHg. The EKG showed marked ST-elevations. The family requested no further therapy.

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