Fatal Multiple Fungal Sinusitis in Neutropenic T- Cell Lymphoblastic Lymphoma Parient

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 .


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.


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


• Trail of endoscopy was done , but failed , because pt was unable to tolerate nasal cleaning .

• Pt need cleaning under General Anaesthesia


• 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

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 .


KAMC-IM-ID-Riyadh.

Fatal Multiple Fungal Sinusitis in Neutropenic T- Cell Lymphoblastic Lymphoma Parient

Health & Medicine

Transcript of Fatal Multiple Fungal Sinusitis in Neutropenic T- Cell Lymphoblastic Lymphoma Parient