50/Male came with altered sensorium
50/Male who is a resident of choutuppal
CT brain showing soft tissue swelling in maxillary sinus
CT brain showing mucosal thickenings of sinus
ENT opinion was taken
KOH mount showing hyphae confirming the diagnosis of Acute rhino oro cerebral mucormycosisi
On the day of admission
Daily wage labourer by occupation
Came with cheif complaints of
Fever since 10 days
Facial puffiness and periorbital edema since 4 days
Weakness of right upper limb and lower limb since 4 days
Altered sensorium since 2 days
History of present illness:
Patient was apparently asymptomatic 3 years back and went to local hospital in/v/o Regular checkup and came to diagnosed with Hypertension since then he was on regulate medication...
And on 18/04/21 He went to local PHC for COVID 19 vaccination.. Since that night patient is complaining of Fever associated with chills and rigors, high grade fever, no diurnal variation which was relieved on medication...
No c/o cold and cough
Followed by patient is having similar complaints after three days and he visited local hospital which is not subsided by medication ( Antipyretics) ( not taken medication such as steroids, oxygen therapy, anti virals)
On 28/04/21 , c/o Generalized weakness and facial puffiness and periorbital edema.. And also patient is in drowsy state..
On 04/05/21, patient presented to casualty In altered state with facial puffiness and periorbital edema and weakness of right upper limb and lower limb...
Day 1-
On presentation,
patient vitals are
Patient is irritable
Facial puffiness +
No serous discharge from eye,
BP - 120/80 mmhg
PR - 106 bpm
CVS - S1S2 +
RS - BAE + , inspiratory crepts noted in B/L
IAA and ISA
GRBS - 141 mg/dl
SpO2 - 98% at room air
CNS - pt is drowsy
GCS - E1V2M5 - 8/15
Reflexes Rt Lt
Biceps - -
Triceps - -
Supinator - -
Knee - -
Ankle - -
Plantar mute withdrawal
Tone :
UL decreased normal
LL decreased normal
Day 1 evening
patient vitals are
Patient is drowsy
Facial puffiness +
serous discharge from left eye,
Periorbital edema progressed,
Serous discharge from left eye, blood tinged
Oral and nasal foul smelling +
BP - 110/80 mmhg
PR - 100 bpm
CVS - S1S2 +
RS - BAE + , inspiratory crepts noted in B/L
IAA and ISA
GRBS - 600 mg/dl
SpO2 - 98% at room air
CNS - pt is drowsy
GCS - E1V2M3 - 6/15
Reflexes Rt Lt
Biceps - -
Triceps - -
Supinator - -
Knee - -
Ankle - -
Plantar mute withdrawal
Tone :
UL decreased normal
LL decreased normal
And abg showing acidosis diagnosed with diabetic keto acidosis and
Opthal opinion was taken for eye discharge and we thought of dd's as necrotising fascitis and planned for CT brain with orbits showing following findings
And DKA correction was started according to algorithm 1
CT was done and images showing
Preseptal cellulitis
CT showing acute infarcts in frontal and temporal lobes
Hemogram showing
Hb - 11.2
Tlc counts - 20,000
N/L/E/M - 87/5/2/6
Pcv - 35.1
Platelets - 1.81 lakhs
Smear showing normocytic normochromic
Neutrophilic leucocytosis
Complete urine examination showing
Albumin 4+
Sugars 4+
Bile salts and bile pigments - nil
Pus cells - 3-5
Epithelial cells - 3-4
Rbc and casts - nil
Urine for ketone bodies - positive
PT - 18sec
APTT - 35 sec.
INR - 1.3
RT PCR for COVID - Negative
HbA1c - 7.5
HIV, HBSAG, HCV - Non reactive ( negative)
Provisional diagnosis : ACUTE ORO RHINO ORBITAL MUCORMYCOSIS WITH DIABETIC KETO ACIDOSIS WITH RIGHT SIDED CVA (ACUTE INFARCT IN LEFT FRONTAL AND TEMPORAL LOBE) WITH DENOVO DETECTED DIABETES MELLITUS 2 WITH AKI AND HYPERTENSION SINCE 2 YEARS
Proposed management -
Inj. Liposomal amphotericin B according to creatinine clearence
Loading dose 30mg/IV over 2-6 hrs
Maintenance dose 60mg / IV once a day
Update on May 5, 2021
The Nasal swab sample has been inoculated in culture medium.
We couldn't get the cranial MRI as he's very restless and couldn't be sedated adequately.
The CT does show an infarct around the left corona radiata (he has right hemiparesis) along with inflammatory exudates in his maxillary and sphenoidal sinuses.
His creat has reduced from 2.4 to 1.7 today.
He has been given 200mg of itraconazole (only drug currently available) adjusted to his creatinine clearance which is 43ml/min
Deoxycholate ampB requirement is 70mg per day
Affordability issues:
Cost of 50mg is 500to 700rupees
Liposomal ampB requirement is 350mg once daily
Where 50mg costs 2400 to 3000 rupees per day
Even the busiest pharmacy in Hyderabad (we called Osmania Medical College pharmacy) doesn't have deoxycholate.
Liposomal is still available for 30% lesser price. Posaconazole price is 15k starting.
And he was referred to osmania general hospital where he was given one dose of deoxycholate amphotericin B and patient has died On 6th may around 10 am.
