April ’12

Medical Student Elective

Case of the Month
April
Submitted by: Zhixi Li, MS4 Columbia P&S

HPI
A 65 year old woman with diabetes mellitus type 2 presents with a chief complaint of right-sided facial swelling, pain, and nasal congestion. Symptoms began 4 days ago with a slight swelling of the right side of her face, associated with pressure, aching pain, and congestion of the right nostril. The swelling increased and she saw her PMD the next day, who diagnosed her with sinusitis and prescribed Augmentin. Since beginning the antibiotic, the swelling has spread over her right face and eye lid, preventing her from opening her right eye, though she does not recall any pain with eye movements. She has been feeling chills and the right face has become numb. She denies any fevers, nasal drainage, and any recent oral or dental infections. No recent travel, trauma to the face, or exposure to animals or insects.


PMH
DM2, HTN, HLD.
Social history: Non-smoker, lives with husband in Washington Heights. No pets.


PE (pertinent)
Vitals: T 99.0 F oral, BP 129/67, PR 88, RR 18, O2 100% on RA, Pain 7/10
Constitutional: Alert and oriented. Tired appearing, no acute distress.
Eyes: Right ptosis with proptosis. On the right eye, there is minimal serous discharge around the edge of the cornea, with moderate conjunctival injection. Left eye is normal appearing.
Face: Moderate swelling, warmth, and erythema extending across the right hemi-face with involvement of the eye lids. Tenderness to palpation over the right maxillary sinus. Right facial droop.

Oral pharynx: moist oral mucosa, no erythema or exudates. No evidence of dental caries.
Neck: No lymphadenopathy.
Neuro: Pupils were equal, round and reactive to light bilaterally. Reduced visual acuity in the right eye. No pain with extraocular eye movements in either eye. R ptosis. R-sided lateral gaze palsy. R-facial droop due to swelling (smile compensates for the deviation). Decreased sensation to light touch over the right face. CN 8-12 normal.

Cardiovascular: Regular rate and rhythm, normal S1S2, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally.
GI: Soft, non-distended, non-tender to palpation. +BS.
Muscloskeletal: No evidence of weakness or tenderness.
Dermatological: No rashes.

LABS
CBC: WBC 11.5 (71.3% N, 22.3 L, 8.3 Abs N)
Finger Stick: 456 mg/dl


Course
The patient was given Toradol and morphine for pain control. After 1 hour, the pain in her right face persisted, and she complained of increased pain in her right eye.


What is the most likely diagnosis for this patient? And the most concerning?
What further tests would you order for this patient?
What are the potential causative organisms in this case?


What is the most likely diagnosis for this patient?

Orbital cellulitis

Most concerning diagnosis?

Cavernous sinus thrombosis (resulting from spread of infection)

What further tests would you order for this patient?

Blood cultures were negative x2
CT maxillofacial and brain with IV contrast:

Axial image (left) at the level of the maxillary sinuses demonstrates air fluid level in the right maxillary sinus and more superiorly (middle) showing hyperdensity extending from sinus into the retro-orbital fat. There is also involvement of the ethmoid sinus. Sagittal image (right) at the level of the right orbit demonstrates erosion of the orbital floor. The cavernous sinus did not show evidence of thrombosis.


Why didn’t this patient respond to Augmentin for presumed sinusitis and what are the potential causative organisms in this case?


Progress
Opthalmology and ENT were consulted in the ED for this patient. She was begun on IV unasyn and IV vancomycin which is the empiric therapy for orbital cellulitis. During day 1 of admission, the patient’s HgbA1c was checked and results showed 14.5. On day 2, the patient lost vision and motor function of her right eye despite empiric antibiotic therapy. ENT cannulated the patient’s maxillary and ethmoid sinuses for tissue and pus cultures, which returned with growth of rhizopus species. IV amphotericin and caspofungin were begun. MRI of the sinuses, orbits, and brain on day 3 showed a new right frontal lobe infarct in the premotor region. An MRA head and neck was performed which did not reveal evidence of vessel invasion. An LP was performed and the CSF was negative for organisms. On day 16, repeat imaging showed stable disease in the sinuses and orbits.


Take home messages
Orbital cellulitis (post-septal) is differentiated from pre-septal cellulitis by the presence of proptosis, vision loss or changes, opthalmoplegia, and painful eye movements.
Mucormycosis is caused by rhizopus, mucor, and rhizomucor species that thrive in ketogenic states because they express ketone reductases. Diabetics and immunocompromised individuals are at increased risk for fungal infections. Delayed diagnosis and initiation of antifungal therapy has been shown to greatly increase mortality from mucormycosis. Suspicion should be heightened in immunocompromised individuals particularly if there is no response to usual antibiotic therapy within 24-48 hours.


Sources
http://www.uptodate.com/contents/fungal-rhinosinusitis?source=search_result&search=fungal+rhinosinusitis&selectedTitle=1~21
http://www.saber.ula.ve/tropical/contenido/capitulo13/capitulo63/figuras/63-0004-en.html


Every month during director’s rounds, our students present interesting and educational cases. This is a synopsis of the case voted to be the best by the students and directors at the end of director’s rounds along with an interesting image.


OR


Medical Student Program Directors

Jamie Edelstein, MD and Chen He, MD
slredmedstuds@gmail.com

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