February 10, 2015 Grand Rounds

Case # 1: 22/F, intravenous drug user (IDU), who p/w acute right-sided hemiparesis secondary to cerebral zygomycosis.

 From: http://www.neurology.org/content/76/1/e1/F1.expansion.html

1. Among IDU's, cerebral involvement represents the most common form of disease zygomycosis. 

2. Suspect cerebral zygomycosis in the setting of IDU, unilateral basal ganglia involvement, rapid progression of a unilateral lesion to involve the contralateral side, and unexplained large infarcts in the brain.

3. Carries a very high mortality rate of almost 70%. Brain biopsy is always almost essential to establish the diagnosis. Of those who died from it, only 1/3 had a diagnosis of zygomycosis before death.

Case # 2. Update and review of measles.

1. Spread by aerosol, droplet, or contact. It is contagious 4 days prior and up to 4 days after the rash.

2. Usual course: 8-12 days of incubation period, followed by 2-4 days of fever, conjunctivitis, coryza, and cough, followed by 2-3 days of rash that begins from the hair line and spreads downward. Koplik's spots are bluish to whitish papules seen in the buccal mucosa 1 day before appearance of the rash and lasts for 2-3 days.

3. As of 2/6/2015, there have been 121 measles cases from 17 states. Illinois (mostly from Chicago) has 3 cases already.

February 3, 2015 Grand Rounds

Case # 1. 60/M with h/o refractory neutropenia secondary to large granular cell lymphoma, h/o kidney transplantation, who p/w acute mental status change, new-onset left axillary skin lesion, and progressive lung nodules and cavity formation secondary to disseminated mucormycosis.

1. Remember the most commonly encountered causes of mucormycosis: Rhizopus, Mucor, and Rhizomucor; Cunninghamella, Absidia, Saksenaea, and Apophysomyces.

2. The three most common disease presentations associated with mucormycosis are: rhinocerebral, pulmonary, and cutaneous mucormycosis.

3. Cutaneous mucromycosis can arise from direct inoculation. Reverse dissemination (from skin to other organ systems) rarely occurs (3%).

4. Treatment of choice is amphotericin. Posaconazole is an alternative agent. Not backed up by randomized controlled trials but combination therapy (amphotericin plus echinocandin, amphotericin plus posaconazole) has also been used for refractory cases. Use of adjunct deferasirox for refractory cases has also been reported.

5. This patient's treatment course was complicated by development of torsades de pointes while receiving a quinolone and posaconazole. QT prolongation persisted despite discontinuation of drugs. In this situation, intermittent amphotericin (once weekly) can be tried. This is supported by a small study where once weekly amphotericin was comparable to other prophylaxis for invasive fungal infection (see here).

Case # 2. A 10 year old girl with cystic fibrosis, s/p bilateral lung transplant, h/o post-transplant lymphoproliferative disorder who p/w persistent abdominal pain and fever; PET scan revealed diffuse uptake in the pancreas; multiple infectious disease work-up were negative; pancreas biopsy showed necrotizing granulomas and yeasts on Giemsa stain; beta glucan was elevated; believed to be secondary to Candida pancreatitis

1. Remember that Cryptococcus and the agents responsible for mucormycosis will test negative for beta glucan. Maybe helpful to distinguish cryptococcal versus candidal infection especially if cultures are negative and yeasts are evident on tissue biopsy.