An elderly female presents with the nasal blockade and nasal discharge with black debris. Blood sugar was raised and urine is positive for ketones. Best treatment for the patient would be:(AIIMS May 2013, Nov 2012)
Ans. a. Amphotericin B (Ref: Harrison 19/e p1350, 18/e p1661)This diabetic patient is most likely suffering from mucormycosis, in which there is involvement of peri-orbital region and visual impairment. I.V. Amphotericin BQ is the treatment most commonly used in all forms of Mucormycosis.Amphotericin B deoxycholate remains the only licensed antifungal agent for the treatment of mucormycosis.'- Harrison 18/e p1664Infections in Diabetes MellitusHyperglycemia aids the colonization and growth of a variety of organisms (Candida and other fungal species).Many common infections are more frequent and severe in diabetic population, whereas several rare infections are seen almost exclusively in the diabetic populationQ.Example in this latter category includes Rhinocerebral Mucormycosis, emphysematous infections of the gall bladder and urinary tract, and malignant or invasive otitis externaQ.MucormycosisSpecies of Rhizopus, Rhizomucor, and CunninhamellaQ are the most common causes of mucormycosis.Mucormycosis originating in the Paranasal sinuses and noseQ predominantly affects patients with poorly controlled diabetes mellitusQ.In all forms of Mucormycosis, vascular invasion by hyphaeQ is a prominent feature.Ischemic or hemorrhagic necrosisQ is the foremost histologic finding.Predisposing Factors* Diabetes mellitus* Organ transplantation recipients* Long-term desferoxamine therapy* Prolonged cytotoxic or steroid treatment* Hematologic malignancies* Chronic renal failureClinical manifestationsCharacteristic picture in nose and paranasal sinus involvementLow grade fever, dull sinus pain, nasal congestion or thin bloody discharge followed in few days by double vision,increasing fever, and obtundation.Examination reveals a unilateral generalized reduction of ocular motion, chemosis, ProptosisQ.The nasal turbinates on the affected site may be dusky red or necrotic.A sharply delineated area of necrosis, strictly respecting the midline, may appear in hard palateQ.Pulmonary Mucormycosis: Manifests as severe pneumoniaCutaneous MucormycosisGI invasion presents as one or more ulcers and then perforatesDiagnosis:Microscopic examination and culture of biopsy:Appear as rod-ribbon like, usually with non-septate hyphae with branch at right angleTreatment:Successful treatment requires early diagnosis, reversal of underlying predisposing factors, if possible, surgical debridement and prompt antifungal treatment.Regulation of diabetes mellitus and a decrease in the dose of immunosuppressive drugs facilitate the treatment.Extensive debridementQ of craniofacial lesions and orbital exenteration if required.I.V. Amphotericin BQ is TOC in all forms of Mucormycosis.
Amphotericin B
Itraconazole
Ketoconazole
Broad spectrum antibiotics
Drugs