Mark Crislip, MD, Infectious Diseases, 10:36PM Oct 7, 2013
I’m back from ID Weak. Sigh. Lots of CME but relatively little learnin’. With all the reading I do for the blog and podcast I do a reasonably good job of keeping up in my field. Wheat mostly. Time spent for information gathered, meetings are really not efficient, but the eating in SF is almost as good as in PDX. And the rule still holds that every day away from work generates 2 days worth of paperwork and labs upon return.
There are occasionally talks with an historical perspective and I enjoy those as I am now old enough to remember how things were back in the day. Medicine has changed dramatically over my career. The first 15 years were marked by endless AIDs related deaths, and I have seen only one of AIDS death this centruy. I do not think I ever cured an invasive mold infection in the old days, now I am surprized if I can’t.
The patient is an elderly make with a hematologic malignancy, on prednisone, who comes in with a week of eye pain then double vision because of a partially fixed eye. He has no proptosis and labs slow a WBC of 0.8 from chemotherapy. Not good.
CT shows a mass in the adjacent sinus and the medial eye muscles next to the sinus are edemetous. Not good.
The worry is rhinocerebral mucor. I have only seen a pair, both last century and both fatal. It is one of those “Oh, expletive deleted” diagnoses where you expect nothing but badness. But that was then, this is now.
He received one antibiotic in each class, a technique ususally reserved for surgical residents and he was wisked off to the OR.
There was a large mass in the sinus that was debrided and it was mostly mucous and some sort of mold on the gram stain and after a couple of days it grew Aspergillus. The patient did fabulously. It is amazing how well patients do with the newer azoles. And surgery. And stopping steroids. And having the WBC return with GCSF. But his pain vanished and his functioned returned and he is now on an arbitrary but prolonged course of voriconazole. The good news is he is done with chemo for now so I do have to worry about recurrence with more neutropenia.
While not as common as mucor, there are cases of rhinocerebral Aspergillus. My patient was lucky as the mold did not move beyond the extraocular muscles into the brain and we could reverse much of his immunosuppression. But I still like me that voriconazole.
The newer azoles, the post ketoconazole medications (I guess some are not so new anymore), have slowly changed mycology treatment. One by one, cryptococcosis, coccidioidomycosis, histoplasmosis, aspergillosis and mucormycoses have been picked off by evolving azoles, going from often fatal to often cured. It as been a welcome change.
BMJ Case Rep. 2013 Feb 5;2013. pii: bcr2012008552. doi: 10.1136/bcr–2013–008552. Rhinocerebral mucormycosis: literature review apropos of a rare entity http://www.ncbi.nlm.nih.gov/pubmed/23389725
Indian J Otolaryngol Head Neck Surg. 1998 Jan;50(1):26–32. doi: 10.1007/BF02996763. Rhinocerebral invasive aspergillosis. http://www.ncbi.nlm.nih.gov/pubmed/23119372