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Review Question - QID 108898

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QID 108898 (Type "108898" in App Search)
A 45-year-old male presents to the emergency room complaining of a four-day history of facial pain that is worsee just below the right eye. It is accompanied by a throbbing frontal headache, rhinorrhea, congestion, and a productive cough. His past medical history is notable for diabetes, obesity, and HIV with a CD4 count of 200 cells/mm^3 and viral load of 1,000 copies/ml. He takes HAART and metformin but admits to missing several doses. His most recent hemoglobin A1c was 11.1%. He has a 20 pack-year smoking history. His family history is notable for ovarian cancer in his mother and stroke in his father. A notable physical examination finding is shown in Figure A. He is exquisitely tender to palpation over the right maxillary sinus. A head CT and biopsy are pending. Administering which of the following is the most appropriate next best step in the management of this patient?
  • A

Azithromycin

11%

10/95

Amoxicillin-clavulanate

8%

8/95

Intranasal beclomethasone

2%

2/95

Amoxicillin

2%

2/95

Amphotericin

65%

62/95

  • A

Select Answer to see Preferred Response

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The patient in this vignette presents with headache, facial pain, and a necrotic black eschar suggestive of mucormycosis. The first-line treatment for mucormycosis is amphotericin.

Mucormycosis refers to several different similar diseases caused by invasive non-septate filamentous fungi of the Mucor order. They are characterized histologically by branches at 90 degree angles. Mucormycosis frequently causes severe rhinocerebral infections in immunocompromised patients with poorly controlled diabetes or hematologic malignancies. Amphotericin is the first-line treatment for patients with mucormycosis. The maxillary sinus is most often affected in adults while the ethmoid sinus is most often affected in children.

Figure A demonstrates a classic mucormycosis lesion. Note the well-defined necrotic eschar overlying the right maxillary region. Illustration A demonstrates the characteristic appearance of mucormycosis on histology. Note the irregular non-septate hyphae that branch at approximately 90-degree angles.

Incorrect Answers:
Answer 1: Azithromycin is a macrolide antibiotic that serves as an alternative to amoxicillin in the treatment of severe cases of bacterial sinusitis caused by S. pneumoniae and H. influenzae.

Answer 2: Amoxicillin-clavulanate contains a beta-lactamase inhibitor for bacterial strains that produce beta-lactamase which can break down antibiotics like penicillin and amoxicillin. M. catarrhalis is a common cause of bacterial sinusitis that produces beta-lactamase leading to resistance to amoxicillin. The recommended agents for use against M. catarrhalis include amoxicillin-clavulanate, second- and third-generation cephalosporins, and trimethoprim-sulfamethoxazole.

Answer 3: Intranasal beclomethasone is used as an adjunctive therapy in patients with acute rhinosinusitis to provide symptomatic relief in patients with milder symptoms.

Answer 4: Amoxicillin is a beta-lactam antibiotic that is used as a first-line therapy for severe cases of bacterial sinusitis caused by S. pneumoniae and H. influenzae.

Bullet Summary:
Mucormycosis is a life-threatening form of sinusitis affecting immunocompromised individuals that should be treated with amphotericin as a first-line therapy.

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