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Infectious Diseases


Answer 2
  1. Obtain an immediate computed tomography (CT) scan of the nose, paranasal sinuses, orbit, and brain and request urgent surgical consultation for possible débridement. 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.

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