Fatal Multiple Fungal Sinusitis in Neutropenic T- Cell
Lymphoblastic Lymphoma patient
Case Presentation
Dr Hythum Salah Hassan Mohamed MBBS-AAHIVS King Abdulaziz Medical City –Riyadh –Saudi Arabia April 2014.
A 24 years old man known to have T- Cell Lymphoblastic Lymphoma since April 2013 , pt was on Chemotherapy , admitted to our Hospital in the 3rd February 2014 as a case of relapse of his hematological malignancy when he presented to the ER complaining of right lower limb and lower back pain for view days prior to admission .
pt admitted under care of Hematology/Oncology team , MRI of back done it was normal , combined chemotherapy protocol started for pt , on day 6 of admission he developed febrile neutropenia and received Antibiotics + Antifungal and his condition showed general improvement .
Dr.Hythum Salah H.Mohamed , MBBS-AAHIVS
KAMC-IM-ID-Riyadh.
About one month after admission he started to develop left side facial pain and left Eye tears , there was no nasal discharge ,swelling or visual problem and that was about in the 3rd of March 2014 .
Ophthalmology Consultation showed normal Ocular Examination , ENT consulted in day 6 of March 2014 , pt examined by using 0-degree rigid scope , which reviled black area of mucosa in middle turbinate of the left side nostril , debridement was done and sample sent for histopathology , impression was fungal infection (mucor aspergillosis ) , management started with Antifungal and other instructions .
Dr.Hythum Salah H.Mohamed , MBBS-AAHIVS
KAMC-IM-ID-Riyadh.
For duration of about 50 days pt was under close follow-up and interventions from ENT and Hematology/Oncology team , also Infectious Diseases team Consulted and initiated Antifungal for different types of Fungal infections by mono and combined antifungal therapy.
One of the main problem was the nasal pain , which started as a mild pain and then progress to become very sever intensive pain .
pain controlled initially by small dose of Morphine from day 14 March 14 and increased up to 6mg /hour infusion + PRN in his last days .
Unfortunately in spite of all efforts done for patient care and management from All medical teams Patient Died in 25th of April 2014.
Dr.Hythum Salah H.Mohamed , MBBS-AAHIVS
KAMC-IM-ID-Riyadh.
ENT Consultation and Follow-up Time Table Finding and Recommendations Procedures Date
• Lt side middle turbinate black mucosal area , query Fungal Infection (Mucor Aspergillosis)
• Antifungal +Nasal Irrigation +improve hydration
Nasal Endoscopy + Debridement +Tissue Histopathology
3 March 14
• Stable pt and no nasal bleeding • Continue same plan .
Follow up 7 March 14
• Stable pt , no signs of active fungal infection or active necrosis
• pt need frequent cleaning of Nasal cavity • Continue the same plane
Follow up +Nasal Endoscopy
11 March 14
As above Follow up 13 March 14
Finding and Recommendations Procedures Date
• Pt is stable • Continue Antifungal and nasal irrigation
Follow up 17 March 14
• Trail of endoscopy was done , but failed , because pt was unable to tolerate nasal cleaning .
• Pt need cleaning under General Anaesthesia
Follow up 20 March 2014
• Black area in the lt side • Augmentin for one week + Antifungal +
Hypertonic nasal saline+ Morphine +platelets infusion .
Nasal Endoscopy + Debridement +Tissue Histopathology
23 March 14
• Wide spread nasal fungal infection Nasal Endoscopy 1st April 14
*lt maxillary sinus necrosis+ Septal necrosis • Rt maxillary sinus necrosis + Rt and middle
turbinate necrosis .• Excision of anterior wall of sphenoid and
partial septum excision .• Antifungal + packing nasal bilaterally with
gauze soaked with Amphotericin B.
Nasal Endoscopy + Nasal Surgery +Debridement +Tissue Histopathology
2nd April 14
Finding and Recommendations Procedures Date
• Pt stable .• Continue same plan .
Follow up 3rd April 14
• Minimal disease progression .• Continue same plan
Nasal Endoscopy + Debridement
9 April 14
• Bilateral nasal clots.• No signs of active fungal infection .• Counties same plan of management
Nasal Endoscopy 17 April 14
Infectious Diseases Consultation and Follow-up Time Table Dose Total
Duration Date Anti fungal
200 mg po q 24 hrs 4 Days 24 Feb 14 till27 Feb 14
Fluconazole
50 mg iv q 24 hrs 9 Days 25th Feb 14 till5th March 14
Caspofungin
• 250 mg iv q 24hrs 6-20 March.
• 300 mg iv q 24hrs 21 March – 13 April .
• 50 mg iv q 24 hrs 14 – 25 April
50 Days 6 March 14 till25th April 14
Amphotericin B lipid complex
200 mg iv q 24 hrs 25 Days 1st April 14 till25th April 14
Voriconazloe
******************** 13 Days 13 April 14 till25th April 14
Voriconazole NasalSolution
Laboratory Investigations Time Table and Results Result Source Investigation Date
Acremonium Species
Rt nostril fluid Fungal Culture 6 March 14 Sample17th March 14 Result
Acremonium Species
Lt nostril Tissue Fungal Culture 6 March 14 Sample19 March 14 Result
No Yeast Isolated Oral Mouth Culture 25th March 14
VRE -----Fusarium Species
Nasal Tissue Tissue Culture 2nd April 14 Sample19 April 14 Result
All were negative , apart from last Blood C/S showed Gram negative bacilli
Blood C/S + Urine C/S +Stool Ova and Parasites
3rd to 25th of April
Surgical Pathology Results Time Table Result Sample Date
Pyogenic granuloma +focal epithelial dysplasia +Mucin infestation by fungal hyphae +nasal mucosa edema and ulceration
Tissue from Lt middle and Lt inferior Turbinate + Lt middle meatus
6th March 14
Invasive Fungal Infection with presence of spores suggestive for Candida Infection No evidence of MalignancyLt Sinus no Fungal infection
Tissue from Lt Nasal cavity and Lt Maxillary Sinus
Note:- they suggest tissue culture as a gold stander diagnostic modality .
23 March 14
Invasive Mucormycosis Tissue from Nasal Cavity 2nd April 14
Bone trabeculae , Cartilage and Fibrin showing invasive Fungal Hyphae .
Tissue from Nasal Cavity 9th April 14
CT Scan Reports Time Table
Report Scan Site Date
Moderate chronic Sinusitis with polypoid thickening in the left paranasal Sinus
Sinus CT 5th March 14
Interval progression of sinus opacification with appearance concerning for sinus involvement by Lymphoma or inflammatory changes including Fungal More bulky Lacrimal glands .. For clinical correlation
Sinus CT 18 March 14
Interval increased opacification of the paranasal sinuses mainly in the Lt and bulky enhancing lacrimal glands also more in the left .
Sinus CT 30 March 14
Pansinusitis with hyperdense lesions with in the maxillary antrum on both sides likely due to fungal infection which could be invasive type or hemorrhage and postsurgical changes .
Brain CT 10th April 14
Nasal CT Scan
Blood Picture
LFTs
Summary
A young 24 years old man known to have T- Cell Lymphoblastic Lymphoma on Chemotherapy , admitted to our Hospital as a case of relapse of hematological malignancy , he received chemotherapy and developed febrile neutropenia about one week of admission , he improved but he continue in neutropenic state through out admission , about one month of admission he developed Fungal Sinusitis with multiple fungal infections , he received intensive course of Antifungal beside surgical interventions and debridement , but unfortunately patient not improved and died .
Dr.Hythum Salah H.Mohamed , MBBS-AAHIVS
KAMC-IM-ID-Riyadh.