Updated: 12/19/2019


Review Topic
1 1
  • A 50-year-old man is brought to the emergency room via ambulance from a fire. He has extensive burns over his arms, torso, and legs. His past medical history is significant for uncontrolled diabetes. On exam, he has periorbital swelling and rhinorrhea. There is a black eschar over his nares and palate. A CT of his sinuses show air fluid levels in his maxillary and frontal sinuses. Biopsy of the black eschar reveals nonseptate hyphae branching at wide angles.
  • Classification
    • Mucor and Rhizopus spp.
      • fungi with irregular, broad, and nonseptate hyphae branching at wide or right angles
      • found in soil and decomposed material
      • transmission via inhalation of spores or direct inoculation (through trauma)
  • Epidemiology
    • risk factors
      • ketoacidosis 
      • uncontrolled diabetes
      • neutropenia
      • hematologic malignancies
      • immunocompromised status
      • trauma
      • burns
  • Pathogenesis
    • inhalation of spores causes germination in nares, sinuses, or lungs, and spread in blood vessel walls
    • invasion into blood vessels cause hemorrhage, thrombosis, and hematogenous spread
    • fungi can penetrate cribriform plate to enter the brain and sinuses
  • Prognosis
    • high mortality
    • rapidly progressive
  • Symptoms
    • headache
    • congestion
    • facial pain
    • sinus pressure
  • Physical exam
    • fevers
      • may be only presenting symptom in immunocompromised patients with pulmonary infections
    • soft tissue swelling
    • black necrotic eschar on face, particularly nares or palate
    • may affect cranial nerves
      • blurry vision
      • loss of ocular motility
    • may have erythematous and necrotic papules and plaques if skin is affected
  • Computed tomography (CT) head/sinuses
    • indication
      • all patients
    • findings
      • air-fluid levels in sinuses
      • mucosal thickening
      • bony destruction
  • Labs
    • culture yield is often low and not useful
  • Biopsy of affected tissue
    • nonseptate hyphae with right-angle or wide-angle branching
  • Making the diagnosis
    • based on clinical presentation and demonstration of fungus in affected tissue
    • high level of suspicion in patients with sinusitis-like symptoms and appropriate risk factors who do not respond to broad-spectrum antibiotics
  • Bacterial sinusitis
    • distinguishing factor
      • does not present with black eschar or rapid progression to brain and cranial nerves
  • Medical
    • amphotericin B
      • indication
        • first-line
    • isavuconazole
      • indication
        • second-line
  • Operative
    • surgical debridement
      • indications
        • all patients
        • in addition to antifungals
  • Death

Please rate topic.

Average 5.0 of 3 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

You have 100% on this question.
Just skip this one for now.

(M2.ID.17.4766) A 54-year-old male presents to the emergency department with facial pain. He reports feeling well until yesterday, when he developed a headache that has gotten progressively worse. The pain has now spread to the right side of his face. This morning he also developed lacrimation of the right eye and double vision. His past medical history is significant for hypertension, hyperlipidemia, type II diabetes mellitus, and end stage renal disease secondary to diabetic nephropathy. The patient’s most recent HbA1c was 12.7%. His home medications include furosemide, lisinopril, pravastatin, metformin, glipizide, and insulin. His temperature is 101.8°F (38.8°C), blood pressure is 155/92 mmHg, pulse is 103/min, and respirations are 16/min. On physical exam, he has proptosis and chemosis of the right eye. Physical exam of the hard palate can be seen in Figure A.

In addition to surgical debridement, which of the following is the treatment of choice for this patient?
Review Topic | Tested Concept

QID: 109050




















L 3 D

Select Answer to see Preferred Response

Topic COMMENTS (0)
Private Note