Critical Care Medicine-Infections and Immunologic Disease>>>>>Systemic Infections
Question 10#

A 47-year-old woman with poorly controlled insulin-dependent diabetes mellitus presents to the emergency room with diabetic ketoacidosis. She reports severe pain in her paranasal sinuses with purulent discharge from the bilateral nares for 1 day. On examination, you notice swelling of the paranasal soft tissues and a dark eschar over the left nasal mucosa.

What is the BEST management strategy?

A. Emergent surgical debridement and liposomal amphotericin B
B. Emergent surgical debridement and voriconazole
C. Blood cultures followed by vancomycin, meropenem, and clindamycin
D. Insulin infusion plus liposomal amphotercin B plus voriconazole

Correct Answer is A

Comment:

Correct Answer: A

This patient has rhino-orbital mucormycosis, which is best managed with a combination of surgical debridement and broad-spectrum antifungal therapy. Voriconazole are not effective against the Mucorales species causing mucormycosis, nor are antibacterial agents. Treating diabetic ketoacidosis, metabolic acidosis, and reducing immune suppression are helpful adjunctive therapies, when possible. Almost all patients presenting with this disease have an underlying predisposing comorbidity, including diabetes mellitus (often with diabetic ketoacidosis), hematologic malignancy, hematopoetic stem cell transplantation, trauma, glucocorticoid treatment, solid organ transplant, AIDS, or malnutrition.

References:

1. Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41:634-653.
2. Jeong W, Keighley C, Wolfe R, et al. The epidemiology and clinical manifestations of mucormycosis: a systematic review and metaanalysis of case reports. Clin Microbiol Infect. 2018.