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.

Clinical ExaminationPyrexialDehydratedPaleTender maxillary & frontal sinuses.Chest & Abdominal examination grossly

normal.

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.

Pt was consented before taking these photographs

Differential Diagnosis?

MRI Brain

CT scan of Sinuses & orbit

ManagementIVF & Intravenous Insulin infusion

Meropenem & TeicoplaninAntiFungal cover initially with

Iatraconazole.

DVT Prophylaxis

Ophthalmologic Evaluation suggested orbital cellulites secondary to maxillary sinusitis.

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

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.

HPE sinus

HPE of sinus

Branching Aseptate HyPhae

AngioInvasion

Zygomycetes Histology

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.

Repeat MRI Brain revealed

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.

Thank You