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N4) Facial pain and epistaxis in an immunosuppressed patient
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with a headache.
- Review the DDx considerations in a patient with a headache.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with a headache.
History
A 50-year-old male with a past medical history of uncontrolled type 2 diabetes mellitus and acute myeloid leukemia (currently on an immunosuppressive regimen) presents with a 1-week history of progressive facial pain, nasal congestion, bloody nasal discharge, and recurrent nosebleeds.
Physical Exam
Vital Signs: BP 130/80 mmHg, HR 90 beats/min, RR 16 breaths/min, Temp 98.7°F, SpO2 98% on room air.
ENT Exam: Perforated nasal septum and nasal congestion. There are areas of black discoloration in the nasal passage. Severe tenderness to palpation over the maxillary sinuses and frontal sinuses.
Labs
CBC: WBC 18,000/uL (Ref: 4,500-11,000/uL), Neutrophils 78% (Ref: 40-60%);
ESR: 45 mm/hr (Ref: 0-22 mm/hr);
CRP: 25 mg/L (Ref: <10 mg/L);
Random Blood Glucose: 300 mg/dL (Ref: <140 mg/dL);
HbA1c: 11.0% (Ref: <5.7%).
Provisional Diagnosis
Select the Dx you believe is most appropriate
Given the patient's immunocompromised status and uncontrolled type 2 diabetes mellitus along with the severe facial pain, black discoloration in the nasal passage, and systemic symptoms, invasive fungal sinusitis seems most likely.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
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This patient requires urgent evaluation due to his immunocompromised status and the risk of invasive fungal sinusitis. Delay in diagnosing and treating invasive fungal sinusitis can lead to serious complications, including intracranial and orbital invasion.
First Imaging Study
What is the first imaging study you will order?
A maxillofacial CT scan without contrast is the imaging modality of choice for patients suspected of having invasive sinusitis. It provides detailed images of the sinuses and nasal passages and can identify complications of sinusitis like bone erosion or spread to adjacent structures.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Maxillofacial CT scan
Which sinuses demonstrate mucoperiosteal thickening?
There is mucoperiosteal thickening in the frontal sinus, bilateral ethmoid air cells, both maxillary sinuses, and the sphenoid sinus.
The nasal septum is normal.
The CT findings reveal a large perforation of the anterior nasal septum with high density material, possibly fungal debris, in the nasal cavity.
There is intracranial extension.
There is no evidence of intracranial extension. This is important to establish given the aggressiveness of this condition.
There are other findings.
There is soft tissue fullness in the left pterygopalatine fossa on the left compared to the right.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
The current imaging studies are sufficient to assess the extent of the sinus disease and there is no evidence of intracranial or intraorbital extension.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The most likely diagnosis is invasive fungal sinusitis. The aggressive pattern of disease with the invasion of the sphenopalatine foramen and pterygopalatine fossa, as well as a large new perforation in the anterior nasal septum are characteristic of invasive fungal disease in an immunocompromised patient.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
This patient requires urgent evaluation due to his immunocompromised status and the risk of invasive fungal sinusitis. Delay in diagnosing and treating invasive fungal sinusitis can lead to serious complications, including intracranial and orbital invasion.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 50-year-old patient with uncontrolled type 2 diabetes mellitus, acute myeloid leukemia, and immunosuppression presenting with symptoms and signs consistent with aggressive fungal rhinosinusitis. The management plan will likely include systemic antifungal therapy, surgical debridement of the necrotic tissues, and improving glycemic control.
Lessons Learned:
- Invasive fungal sinusitis is an aggressive opportunistic infection often seen in immunocompromised patients, such as those with poorly controlled diabetes, hematological malignancies, or those on immunosuppressive therapies.
- CT is the imaging modality of choice for the initial evaluation of sinusitis, but MRI might be needed if intracranial or intraorbital extension is suspected.
- The clinical symptoms of invasive fungal sinusitis can be nonspecific; hence a high index of suspicion is necessary in high-risk patients.
- Antifungal therapy and surgical debridement are the mainstay of treatment, along with managing the underlying conditions that led to immunosuppression.
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