case presentation 1 icu
TRANSCRIPT
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Case 150 yr male Background: Poorly controlled DM-type 2 (HbA1c- 12.8)
Presents to ED with a 2 day H/O high fever, headache & Rt sided Facial swelling.Noted to be septic with pyrexia, hypotension & tachycardia. CBGs were persistently >500.
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Clinical ExaminationPyrexialDehydratedPaleTender maxillary & frontal sinuses.Chest & Abdominal examination grossly
normal.
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InvestigationsTC- 33780; 93% NeutrophilsHb – 4.8Cr- 3.9 CRP- 217 CXR- clear ABG – Not Acidotic, Urinary Ketones AbsentESR-15 CoCa-7.5Iron studies- Ferritin- 2354, Se Fe- 20, TIBC- 180ANA, ANCA negativeSerum Electrophoresis- No Monoclonal Bands.
USS Abd- Mild HepatomegalyBlood cultures & Urine cultures sent.Nasal Scrapping sent.
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Pt was consented before taking these photographs
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Differential Diagnosis?
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MRI Brain
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CT scan of Sinuses & orbit
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ManagementIVF & Intravenous Insulin infusion
Meropenem & TeicoplaninAntiFungal cover initially with
Iatraconazole.
DVT Prophylaxis
Ophthalmologic Evaluation suggested orbital cellulites secondary to maxillary sinusitis.
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The ENT team reviewed the patient, Flexible nasal endoscopy done which revealed RT Maxillary sinus mucosal thickening.
FESS & Endoscopic clearance of the RT nasal cavity was performed.
OT note- Blackish pultaceous material was noted in the RT nostril highly suggestive of Fungal Rhino sinusitis. Debridement of the Frontal, Maxillary & Ethmoidal sinuses were performed. Tissue sent for HPE.Anterior & Posterior Ethmoidectomy done
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Post operative ManagementBased on the Macroscopic findings
during OT pt was started on aggressive Antifungal Therapy
Posaconazole- 200mg TDS (Amphotericin B initially not considered
as pt had Diabetes related CKD)
Pt was also started on Iron Chelation therapy with Deferiprone 1500mg TDS.
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HPE sinus
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HPE of sinus
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Branching Aseptate HyPhae
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AngioInvasion
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Zygomycetes Histology
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The Patient continued to remain unwell c/o persistent headache, Lt sided weakness & Rt eye pain.
TC & CRP were still high 13200 (33780) & 124(217).
ENT evaluation revealed recurrent crusting & a repeat FESS was advised.
However we did a repeat MRI, to asses disease spread.
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Repeat MRI Brain revealed
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Aggressive AntiFungal Therapy
Amphotericin B lipid complex was started dose 3-5mg/kg.
Posaconazole stopped.Iron chelation is being continued.
Dramatic response to therapy, headache now completely resolved, RT swelling improved.
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Thank You