What's Bugging You?

“What brought you in today?” I asked the middle-aged gentleman with an ongoing low-grade fever.

“Taxi,” he replied.

"Hmm, I guess you’re not feeling too terrible if you can make corny jokes like that," I replied with a smile.

“Actually,” he replied, “I don’t feel well at all. I’ve had a fever on and off for over a week now, I have no energy, and my eyeball is constantly throbbing.”

In fact, he did appear to be in quite a bit of discomfort. He was pale, looked exhausted, was holding his left palm over his left eye, and had something black in his nose.

What the heck -- something black in his nose? What was that? I looked closer, got out my dollar-store flashlight, and determined that it wasn’t blood and didn’t seem to be necrotic tissue. In fact, it looked a lot like watery black discharge.

“Can I look in your mouth?” I asked. He opened wide, and in the posterior portion of his soft palate on the left-hand side, there appeared to be some additional swelling and inflammation.

My differential diagnosis was starting to narrow.

I tapped my finger over his frontal and maxillary sinuses. "Does that cause discomfort?" I asked.

“Yes, it does,” he said, putting his hand over his eye again as soon as I had finished.

“Hmm. We should get a CT of your sinuses today," I suggested. “It seems you have some sort of inflammation in there, and I think we need a good look at what that might be.”

Mr. S. had been neutropenic for more than three weeks and also had a history of hyperglycemia caused by the steroids that he was taking as treatment for his multiple myeloma. He was a sitting duck for all kinds of infections, and that black drainage from his nose was very worrisome. "Does he have mucormycosis?" I wondered. I’d never seen a case of it, but I had heard of it, though I didn’t remember a lot about it. I did remember that it was an oncologic emergency that required timely intervention.

Off he went for the CT, and while he was gone, I grabbed a coffee, tasteless but reasonably priced (I’m on a budget), and came back to quickly look up mucormycosis. I discovered that surviving mucormycosis depends on rapid diagnosis followed by aggressive medical and surgical therapy. Doing one without the other is described in the literature as being suboptimal therapy and would likely result in treatment failure.

I received a call from the radiologist even before Mr. S. returned to the clinic. The scan revealed what looked like a large fungal ball in the left maxillary sinus with some degeneration of the bone noted. I informed the primary physician, and she arranged for a rapid ENT consult. Mr. S was admitted. The following day, a surgical debridement determined that his lesion was highly suspicious for mucormycosis, and long-term Amphotericin was ordered.

Mr. S. had many risk factors associated with developing invasive mucormycosis including hyperglycemia, neutropenia, increased iron, and steroid use. His risk factors were subsequently decreased by providing Neupogen and taking him off of his steroids, which also lowered his glucose.

Not too long ago, I went to visit him in hospital.

“What brought you here?” he asked.

“Taxi,” I replied with a grin.

For more information and some graphic photos related to mucormycosis, check out this page.