Patients with diabetes mellitus, particularly in ketoacidosis, who present with such
clinical features must be suspected of having an invasive fungal infection involving
the rhinoorbital region. Early symptoms mimic those of bacterial sinusitis; therefore,
it is critical to assess the extent of disease involvement and then arrange for
débridement, biopsy for histology, and cultures before initiating empiric
antimicrobial treatment. This patient has zygomycosis, which is an uncommon fungal
infection caused by species of Rhizopus, Rhizomucor, Absidia and Cunninghamella.
It affects patients with serious preexisting diseases such as diabetic ketoacidosis,
acute leukemia, and uremia. The case patient demonstrates the characteristic clinical
presentation of zygomycosis originating in the nose and paranasal sinuses. The
mainstay of therapy is surgery. Extensive débridement of craniofacial lesions is
essential, and at times orbital exenteration may be required. Frequently, repeated
débridement is necessary. High dose IV administration of amphotericin B (1 - 1.5 mg/kg
of body weight) is of value; in patients intolerant of amphotericin B, one of the
lipid formulations may be used. None of the currently available azoles has any role
in the treatment of this infection.
- Obtain an immediate computed tomography (CT) scan of the nose, paranasal sinuses,
orbit, and brain and request urgent surgical consultation for possible débridement.
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Hospital Physician Board Review Manuals
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