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Washington University Experience | INFECTION | Fungus | Mucormycosis - Zygomycosis | 11A0 Case 11 History
Case 11 History ---- The patient was a 42 year old woman with a past medical history significant for poorly controlled diabetes mellitus type 1, psoriatic arthritis on methotrexate, chronic hypertension, hyperlipidemia, and hepatitis C who presented to our hospital on 10/26 from an outside hospital with concern for rhino-orbital-cerebral-invasive zygomycosis with right septic cavernous sinus thrombosis and angioinvasion of right cavernous ICA with resultant right ACA and MCA extensive ischemic infarct. ---- The patient was last known to be at her baseline at approximately 9:30 PM on 10/25. Sometime after, she experienced sudden left-sided weakness involving her face, arm, and leg and was evaluated at an outside hospital for stroke the next day at 1:00 AM with an NIH Stroke Scale Score of 27-28. At the outside hospital the patient was given IV alteplase. Her blood glucose values were > 500 mg/dl, and there was concern for diabetic ketoacidosis. She was transferred to Barnes Jewish Hospital for further management and evaluation for thrombectomy. At BJH, the patient's NIH Stroke Scale Score was 20, with loss of consciousness, left field cut, left-sided weakness and sensory loss, and hemineglect. A head CT was obtained, demonstrating ischemic changes in the territory of the right MCA and complete opacification of her right maxillary sinus and partial opacification of the right frontal sinus. A CT angiogram was negative for large vessel occlusion, but there was a paucity of right MCA territory vessels visualized. Prior to her most recent hospital admission, the patient had a history of recent headaches, sinus infections, and had failed multiple courses of antibiotics. In the BJH ED, the patient was evaluated by ophthalmology who performed a dilatated eye exam. Per their note, the patient's intraocular pressure was 14, but the changes in her right eye were concerning for ophthalmic artery/retinal artery occlusion/ischemia. Given their clinical examination, there was also concern for infectious processes, including mucor and preseptal cellulitis. During her hospital course at BJH, the patient was transferred to the NNICU under the Stroke service for care. On 10/26 she went to the operating room for right orbital decompression, maxillary antrostomy, ethmoidectomy, sphenoidotomy, frontal sinusotomy. Status post debridement, the patient developed a hemorrhagic conversion and malignant cerebral edema complicated by brainstem compression, requiring emergent craniotomy on 10/27. Following surgery, she had minimal improvements in her neurological exam. She progressively worsened and cerebral edema was refractory to mannitol and hypertonic solutions in the appropriate range. Head CT on 10/28 showed a large territory of infarcted brain spanning the right anterior cerebral, right middle cerebral, and perhaps portions of the right posterior cerebral artery. Given her worsening prognosis, the goals of care were redirected towards comfort on 10/29 and she expired the same day.
