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Amphotericin and surgical debridement
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This patient with a history of poorly controlled type I diabetes and likely diabetic ketoacidosis has a facial lesion consistent with diabetic ketoacidosis. The most appropriate next step in management for patients with suspected mucormycosis is surgical debridement and administration of amphotericin.Mucormycosis is a fungal infection that occurs almost exclusively in immunocompromised patients such as those with diabetes and diabetic ketoacidosis, or patients receiving prolonged steroid courses. Rhizopus and Mucor species are most commonly implicated. Because mucormycosis is caused by inhaled spores of mold, patients typically present with symptoms related to the nose and sinuses, including facial pain, nasal congestion, and purulent nasal discharge. The infection can then spread beyond the sinuses to the palate, orbit, and brain. This can cause palatal eschar, proptosis, and ophthalmoplegia, as is seen in this patient. Mucormycosis appears as broad, non-septate hyphae with wide-angle branching (Illustration A). Cornely et. al review the management of mucormycosis. They discuss the association of this disease with diabetic ketoacidosis and other etiologies of severe immunocompromise. They recommend that patients be managed with aggressive surgical debridement and amphotericin.Figure A shows a facial lesion consistent with mucormycosis. Note the black, eschar appearance of the lesion.Illustration A demonstrates the appearance of Rhizopus, the most common causative organism of mucormycosis. Rhizopus appears microscopically as broad, non-septate hyphae with wide-angle branching that approaches 90 degrees.Incorrect Answers: Answer 1: Amphotericin is the antifungal medication of choice for patients with suspected mucormycosis. However, medical management alone is not sufficient. Patients require aggressive surgical debridement, often with multiple repeat debridements.Answer 3: Capsofungin is an antifungal medication used to treat various fungal infections such as those due to Candida species. However, it is not utilized in the management of mucormycosis.Answer 4: Trimethoprim-sulfamethoxazole is the treatment of choice for Nocardia, which presents as a pulmonary, central nervous system, or cutaneous infection in immunocompromised individuals. It is unlikely to present as an isolated infection of the face or sinuses.Answer 5: Voriconazole may be used in invasive aspergillosis and some forms of candidiasis, but it does not play a role in the treatment of mucormycosis.Bullet Summary:The most appropriate next step in management for patients with suspected mucormycosis is surgical debridement and administration of amphotericin.
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