HSC Section 8_April 2017

FUNGAL MOE: PITFALLS, DIAGNOSIS, AND TREATMENT

had decreased to 65 mm/h. The patient was discharged on oral voriconazole 200 mg twice a day for 2 months. While on the medical service, his blood glucose level was also brought under control.

Patient 2 An 85-year-old woman with a history of poorly con- trolled Type 2 DM and hypertension presented with a 3-month history of right ear pain. She was initially treated with oral and intravenously administered antibiotics, in- cluding quinolones, with no improvement. She had a his- tory of penicillin allergy. She was admitted with vomiting and severe headache that prevented sleep. Examination showed an edematous right ear canal with granulation tissue inferiorly. The canal was filled with squa- mous debris, and the tympanic membrane could not be visualized. She had an intact facial nerve function. Erythrocyte sedimentation rate on admission was 93 mm/L, and an ear swab showed S. epidermidis and Candida albicans . Tissue cultures were negative. Computed tomographic scan of the temporal bones showed inflammatory changes of the right middle ear and external auditory canal (Fig. 5). Magnetic resonance image of the brain showed signif- icant soft tissue infiltration and edema involving the infra- temporal fossa, masticator, parotid and parapharyngeal spaces, right temporalis muscle and subcutaneous soft tissues. Associated mild dural enhancement of the floor of the right middle cranial fossa (Fig. 6). Bone and gallium scans showed intense uptake in the right temporal bone involving the petrous apex. The patient was given intravenously administered az- treonam 2 g every 8 hours for 3 weeks and was then dis- charged on oral ciprofloxacin 500 mg twice a day. The pain improved and ESR dropped to 83 mm/h. However, she was readmitted 2 weeks later with right facial nerve palsy and recurrent ear pain. Her ESR rose to 105 mm/L.

The right ear canal was very edematous with squamous de- bris, and the tympanic membrane could not be observed. The patient underwent debridement of the external ear canal down to the tympanic membrane. There was a mound of granulation tissue in the middle ear but not in the ex- ternal ear canal. Pathology was negative for malignancy, and tissue cultures were positive for Aspergillus species. The patient was, therefore, began receiving intravenously administered amphotericin B lipid 400 mg once-daily complex for 4 weeks, but the medication was discon- tinued because of renal impairment. Meanwhile, the pain resolved, and ESR dropped to 35 mm/h. Examination showed a normal right ear canal with an intact tympanic membrane. The patient also showed some improvement in function of the lower facial nerve. She was discharged on oral voriconazole 200 mg twice a day for another 2 months. Her blood glucose level had also been brought under control. She remained pain free for another 6 months, when she died as a result of an unrelated cause. Patient 3 A 70-year-old woman with a history of poorly con- trolled Type 2 DM and hypertension presented with a 3-month history of left ear pain. She had been treated with oral and local antibiotics with no improvement of symptoms. Examination showed a dull tympanic membrane, with normal ear canal. The nasopharynx was also normal. An audiogram showed a right, downsloping, moderate sen- sorineural hearing loss and a left mixed hearing loss with FIG. 6. Coronal magnetic resonance image of the brain shows significant soft tissue infiltration and edema involving the infra- temporal fossa, masticator, parotid and parapharyngeal spaces, right temporalis muscle and subcutaneous soft tissues. Asso- ciated mild dural enhancement of the floor of the right middle cranial fossa.

FIG. 5. Coronal computed tomographic scan of the temporal bones shows inflammatory changes of the right middle ear and external auditory canal.

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