Discussion: Rhinocerebral mucormycosis has the potential to be encountered in almost any immunocompromised individual presenting with altered mental status. In our patient, the differential diagnosis involved treatable causes including acute liver failure, diabetic ketoacidosis, Wernicke’s encephalopathy, and sepsis of unknown source. Because of nonspecific findings, a high index of suspicion should be made in the existence of risk factors. Management of rhinocerebral mucormycosis is a medical emergency requiring prompt treatment with amphotericin B and surgical debridement. Despite these measures, the survival of patients without brain involvement is between 50-80% and significantly drops to 20% with brain involvement.
an enlarged liver with mass effect on the inferior vena cava. Initial head imaging was unremarkable but despite appropriate treatment for diabetic ketoacidosis and hepatic encephalopathy, the patient continued to experience worsening encephalopathy and fevers. Repeat CT of the head showed bifrontal edema which was difficult to discern on prior imaging due to artifact. Given the patient's clinical course and imaging findings, a fungal etiology was suspected. Otorhinolaryngology confirmed the diagnosis of mucormycosis with nasal endoscopy. The patient was debrided and started on amphotericin b. Unfortunately, he continued to deteriorate and expired.
“DO I HAVE A CHANCE”—THE USE OF ANGIOVAC SYSTEM IN A HIGH SURGICAL RISK PATIENT WITH AORTIC VALVE ENDOCARDITIS. Andikan Udoh MD, Kubiat Udoh MD, Akash Shah MD, Raja Saravanan MD, Sriveni Tangellapelli MD, Breanna Campbell MD; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Angiovac is a minimally invasive system approved for extraction of right-sided cardiac soft masses and embolic material in patients who are poor surgical candidates. Off-label use of the system has infrequently been prescribed in left-sided cardiac pathology and yielded encouraging results. Case: An 85-year-old male with refractory chronic lymphocytic leukemia not on chemotherapy, multiple episodes of bacteremia (methicillin-resistant staphylococcus aureus [MRSA], Streptococcus agalactiae and enterococcus faecalis), atrial fibrillation and bioprosthetic aortic valve replacement due to aortic stenosis presented with fever, weakness and erythematous rash that started after receiving the Respiratory Syncytial Virus and high-dose flu vaccines one day prior to presentation. He was febrile and tachycardic with an irregular rhythm. The cardiovascular examination was unremarkable and a diffuse urticarial rash over his torso was appreciated. Labs showed a WBC of 64 K/uL with lymphocytic predominance and no eosinophils. He was treated for presumed allergy to vaccines but started to spike fevers and he was empirically
started on broad spectrum antibiotics. Blood cultures grew MRSA. A transesophageal echocardiogram (TEE) was obtained because of inconclusive transthoracic echocardiogram (TTE), and it showed bioprosthetic aortic valve vegetations (largest-4cm). He was deemed a poor surgical candidate and he underwent a successful Angiovac debulking (90%) of the prosthetic AV vegetations eight days following admission. His procedure was complicated by post-op respiratory insufficiency and left common femoral artery injury that required angioplasty with endarterectomy. Post-procedure, he continued to spike fevers and repeat blood cultures grew coagulase positive staphylococcus. Post-procedure TTE had no evidence of aortic valvular dysfunction. Discussion: The primary goal of the Angiovac system in endocarditis is for vegetation debulking to allow reduction of microbic burden and reduce embolic risk. This procedure can paradoxically increase embolization risk intra-operatively and cause vascular access complications. Fiocco et al combined this procedure with a cerebral embolism protection device to mitigate the embolization risk.
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