an uncontrolled diabetic on traditional medicine had nasal discharge head ache on the right side initially rapidly progressed headache, came to us in disoriented state blackish mass in place of the entire nose, gcs 10/15 what are the d.ds and management options.



This is a case of 1) Uncontrolled T2 DM 2) On traditional medicine for DM 3) Rapidly progressing headache 4) Disorientation in time and space. 5) GCS 10/15 6) ??? Malignancy Nose May be secondaries in Brain. 7) ??? Extensive Mucormycosis 8) Cellulitis Face. Investigations 1) FPG 2) 2hr PG 3) HbA1c 4) RFT 5) Serum Electrolytes 6) X Ray Skull AP & Lateral views 7) Biopsy of the mass from all quadrants 8) CT Brain 9) MRI Brain 10) Urinary and Serum Ketones. Management. 1) Admission in ICU 2) Team of Doctors include Endocrinologist ENT Surgeon Neurosurgeon Neurophysician Intensivist. 3) Depending on the DKA or Non DKA Treat with Insulin Correction of Electrolytes Correction of Dehydration with NS. 4) Parenteral antibiotics. 5) ??? Amphotericin B. 6) Maintenance of Vitals. Rest of the treatment depends on the investigations. Real wonderful case. Congratulations for presenting a nice case.

Death is inevitable

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Respected sir, Thanks for the case. This is a classical clinical picture of a fungal infection of nose and paranasal sinuses called "MUCORMYCOSIS" which appears as a black necrotic mass filling the nasal cavity, eroding the septum and hard palate in a predisposed uncontrolled diabetic and may prove rapidly fatal. From the nose and sinuses, infection can spread to orbit, cribriform plate, meninges and brain. The rapid destruction associated with the disease is due to affinity of the fungus to invade the arteries and cause endothelial damage and thrombosis. Special stains help to identify the fungus in tissue sections. Differential Diagnoses: 1) Anthrax, 2) Aspergilloses, 3) Cellulitis, 4) Colonic Obstruction, 5) Nocardiosis, 6) Pulmonary Embolism, 7) Sinusitis. Treatment : Amphotericin B and surgical debridement of the affected tissues and control of underlying predisposing cause. Thank you very much sir, Best regards.

I really love a good pathologist who has the patience and interest to explain the pathological basis of disease. in this present day scenario of computerised labs, MRI CT, polydiagnostic centres, a class apart pathologists like you are slowly becoming extinct

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yes this is a case of mucor, actual rhinocerebral mucor mycosis if you look closely the entire mid face region. is swollen with inflammation of the fungus and due to microvascular thrombosis tissue necrosis. so that whole area turned into a foul smelling mass. this attracted flies and they followed with maggots (you can see them all around the edges if you look closely) even the right frontal sinus is bulging marking it's involvement too, it's through this sinus, cribriform region and the microvascular spread that the fungus reached the brain. the patient was subjected to extensive debridement but as it's a known fact it has a very high mortality rate he succumbed to the fungus within hours of reaching the hospital. post debridement you can clearly see the characteristic black strands and discharge.

Really a good case but may he recovers very soon.

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A humble request to all non allopathic doctors, please understand limitations of their science. do not treat cases of hypertension and diabetics with only alternative medicine. I have come a cross many cases in which patients said he stop taking allopathic medicine and now on alternative medicine with disastrous consequences. I my self is homeopathic dr. many of my colleagues may not agree with this. since ours is noble profession do not harm patients in the name of different science. on allopathic science billions of dollar spent on research world wide for the benefit of man kind.

world health organizations and many other organizations recording what is good for man kind base on research and extensive clinical trials.

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what I wanted to convey to you colleagues is in case of immunocompromised, DM where they under go periodically eye, feet, cardiac,renal evaluation please send them for sinusal evaluation too it costs nothing just a diagnostic nasal endoscopy. but patients usually realise they have a fungal sinus disease only when they end up in complications. like above which almost always results in death

You are 100% correct dear Siddharth, I decided to follow your advice with immediate effect. In fact every one should.

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the other DDs that should be kept in mind are 1.malignant/destructive midline granuloma or t cell lymphoma 2.anthrax 3.extensive squamous cell carcinoma. 4.basal cell ca. 5.nonspecific cellulitis/neglected vestibulitis

Dear Siddharth, I mentioned all in a very methodical way. Just comment on my answer.

Only 3 possible differential...mucormycosis...midline lethal Stewart is take biopsy.. Send it for histopath and fungal examination

please read the above discussions and images I put up in the replies

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almost 100% mortality despite extensive debridement and amphoterecin therapy. very dangerous condition.

Exactly dear Zuber, has to die, no other go in this case, no time given for the doctors to save him.

It's a typical case of mucormycosis with uncontrolled DM where prognosis poor

Mucormycosis... Urgent debridement by ent ssurgoen and start amphotericin b

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