case study icu

1. Case 1
50 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.

2. Clinical Examination
Pyrexial
Dehydrated
Pale
Tender maxillary & frontal sinuses.
Chest & Abdominal examination grossly
normal.

3. Investigations
TC- 33780; 93% Neutrophils
Hb – 4.8
Cr- 3.9 CRP- 217
CXR- clear
ABG – Not Acidotic, Urinary Ketones Absent
ESR-15 CoCa-7.5
Iron studies- Ferritin- 2354, Se Fe- 20, TIBC- 180
ANA, ANCA negative
Serum Electrophoresis- No Monoclonal Bands.
USS Abd- Mild Hepatomegaly
Blood cultures & Urine cultures sent.
Nasal Scrapping sent.

4. Pt was consented before taking these photographs

5. Differential Diagnosis?

8. MRI Brain

12. CT scan of Sinuses & orbit

13. Management
IVF & Intravenous Insulin infusion
Meropenem & Teicoplanin
AntiFungal cover initially with Iatraconazole.
DVT Prophylaxis
Ophthalmologic Evaluation suggested orbital
cellulites secondary to maxillary sinusitis.

14. 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

15. Post operative Management
Based 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.

16. HPE sinus

17. HPE of sinus

18. Branching Aseptate HyPhae

19. AngioInvasion

20. Zygomycetes Histology

21. 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.

22. Repeat MRI Brain revealed

23. 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.

24. Thank You