sinus pain and rhinorrhea in a HIV+ patient
The patient is a middle-aged male with past medical history significant for HIV on antiretrovirals (last CD4 count in the 600s) and poorly controlled diabetes mellitus who presented with rhinorrhea and facial pain.
The patient’s symptoms started four days ago. He describes intermittent, thick, yellow rhinorrhea from the left nare over this time period associated with headaches, anterior facial pain and tenderness to palpation of his face on the left. He reports subjective fevers, but denies chills, sore throat, cough, shortness of breath or chest pain. No recent travel. He reports compliance with his antiretroviral medications but admits to difficulty controlling his blood glucose at home.
Vitals: T 37.5 HR 87 BP 148/90 RR 16 SpO298% RA
Physical Exam: The patient is an alert, well-developed male in no acute distress. HEENT exam is notable for scant yellow, mucopurulent discharge from the left nare. Auricular examination is unremarkable. He does have tenderness with palpation of the maxillary and frontal sinuses on the left. There is no proptosis. Cardiac and pulmonary exams are unremarkable. Neurologic exam is unremarkable.
WBC: 16 CRP: 59.2 Lactate 2.3
Hemoglobin A1C: 14.4
Head CT without contrast as above
ENT was consulted given the concern for fungal sinusitis. Bedside flexible laryngoscopy was performed in the Emergency Department and revealed thick mucoid secretions in the left nasal cavity. The patient was admitted to the hospital, and it was determined that the patient would undergo functional endoscopic sinus surgery (FESS) with ENT.
The patient underwent FESS and was noted to have a large burden of left-sided sinusitis. A left maxillary antrostomy and left sphenoidotomy with removal of tissue from both sinuses was performed, as well as left total ethmoidectomy and left frontal sinusotomy. There was low clinical suspicion for mucormycosis given a lack of obvious necrosis. Nevertheless, the patient was started on amphotericin B empirically. Surgical pathology revealed mucosa with chronic inflammation, moderate eosinophilia, and fibrosis.
Ultimately, cultures grew out Alternaria species. Amphotericin was discontinued, and the patient was started on a six to 12 month course of itraconazole. The patient was discharged to a SNF and subsequently home with home health care with continued antifungal coverage. He continues to have difficulty managing his diabetes medication and maintaining adequate control of his blood sugar.
Fungal sinusitis is commonly divided into five categories: acute necrotizing (fulminant), chronic invasive, chronic granulomatous invasive, fungal ball, and allergic. The former three of these are considered invasive, whereas the latter two are considered non-invasive. Invasive fungal sinusitis implies the presence of fungal hyphae in the mucosa, submucosa, blood vessels, or bone of the paranasal sinuses, whereas noninvasive sinusitis lacks the presence of fungal hyphae in the mucosa or tissues.
Acute necrotizing fungal sinusitis generally occurs in immune-compromised patients, including diabetic patients, patients with HIV/AIDS, and those patients receiving cytotoxic or immune-suppressing drugs. The incidence of this disease is difficult to ascertain, given declining autopsy rates, as well as empiric treatment of patients without histological or microbiological proof of infection. Interestingly, of immune-compromised patients, HIV patients are less commonly infected, although they still remain at risk. Mucor and Rhizopus species are commonly implicated. Patients may present with cough, fever, purulent nasal discharge, epistaxis and headache. Tissue samples will reveal hyphae and often reveal significant tissue necrosis. Speciation requires successful culture of the organism.
Treatment includes surgical debridement, intravenous Amphotericin B, and, to the extent possible, resolution of the underlying immunodeficiency. Diagnosis is critical, as untreated invasive fungal sinusitis has a reported mortality rate of between 50 and 80%. Our patient’s culture was ultimately positive for Alternaria, a fungal species commonly found both in soil as well as indoor environments. The findings of chronic inflammation and eosinophilia suggest an allergic versus chronic invasive nature to the patient’s sinusitis, rather than acute necrotizing sinusitis. Although HIV+, our patient had a CD4 count greater than 600. As such, the patient’s poorly controlled diabetes (HbA1C > 14) was the likely causative agent underlying the patient’s infection.
Authored by Jeremy Liebman, MD Posted by Grace Lagasse, MD
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