Chest Infections: Chest Infections II |

Invasive Fungal Sinusitis With Rhizopus in a Patient With Refractory Leukemia FREE TO VIEW

Abhay Vakil, MD; Saira Ajmal, MD; Alan Wright, MD
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Mayo Clinic, Jamaica, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A122. doi:10.1016/j.chest.2016.02.127
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SESSION TITLE: Chest Infections II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Although rare, invasive fungal sinusitis (IFS) is the most aggressive form of sinusitis seen in patients with underlying immunologic dysfunction. We report the case of a 60-year-old male with a known history of refractory leukemia presenting with sudden-onset facial swelling, nasal discharge, high-grade fever and hemodynamic instability. Imaging studies revealed changes suggestive of IFS. The patient was started on Amphotericin and underwent extensive surgical debridement. Histopathologic examination of the tissue confirmed Rhizopus species causing IFS.

CASE PRESENTATION: A 60-year-old male with a known history of refractory leukemia, treated with multiple chemotherapeutic regimens in the past, presented with sudden-onset right-sided facial swelling and nasal discharge. He denied any visual abnormalities; however, reported a high-grade fever (Tmax 39 C) for the last 24 hours. His last chemotherapy was 3 weeks prior. On presentation he was taking hydroxyurea. In addition, he was on voriconazole for fungal prophylaxis. On examination he was hypotensive (80/55 mm Hg), tachypneic (23/min), tachycardic (132 beats/min) and febrile (38.8 C). Facial examination revealed edema over his right maxillary sinus as well as around the right orbit. Laboratory data showed a leukocyte count of 19.4 with 3% neutrophils. Computed tomographic imaging of the sinuses exhibited necrotic changes involving the right nasal cavity (Fig. 1a) with maxillary fat pad infiltration; concerning for an invasive fungal disease. The patient was started on Amphotericin and taken for emergent debridement. On surgical exploration he was found to have necrotic material within the right maxillary sinus extending into the right nasal cavity. He underwent extensive debridement and packing of the cavity with Amphotericin soaked foam. Histopathologic examination of debrided tissue confirmed IFS with Rhizopus species (Fig. 1b). The patient currently continues to be on Amphotericin for treatment, with ongoing discussions regarding goals of care. In view of his IFS and underlying refractory leukemia, his prognosis remains extremely poor.

DISCUSSION: The reported incidence of IFS in immunocompromised hosts is around 2%, with patients having hematologic disorders being the most susceptible. IFS is associated with extremely high morbidity and mortality, which increases with a delay in diagnosis and treatment. Prompt recognition with early surgical debridement and Amphotericin therapy has resulted in improved overall survival. However, prognosis depends on the underlying condition leading to immunosuppression.

CONCLUSIONS: Early recognition followed by emergent surgical debridement and Amphotericin therapy serve as key factors improving outcomes in patients with IFS.

Reference #1: Turner J. et al. Survival outcomes in acute invasive fungal sinusitis: systematic review and quantitative synthesis of published evidence. Laryngoscope. 2013 May;123(5):1112-8.

DISCLOSURE: The following authors have nothing to disclose: Abhay Vakil, Saira Ajmal, Alan Wright

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