A 43 y.o. female complains of "parasites coming out of her mouth and nose"
the triage complaint was:”. Pt concerned she as a parasitic infection. Over the last several months, pt reports coughing up blood with parasites in sputum. Pt endorses sensitivity to light, water and touch. Also complaining of HA, visual and auditory hallucinations, and neck stiffness. Pt reports to this RN, "there is about a million amoeba parasites that come out of my nose and mouth every day. It feels like one of the parasites is blocking my throat."
this is coming from her nose and mouth
she has a history of rheumatoid arthritis, ankylosing spondylitis and is a transgender female. You notice 1/22 she had a ct of the sinuses showing erosion of the posterior wall of the L maxillary sinus.
What is going on?
Our patient had sinusitis and grew methicillin sensitive staph aureus from her nasal cavity. She underwent a maxillary antrostomy but represented to the ED several months later with black nasal discharge. She had chronic sinusitis which is diagnosed when the sinuses are inflamed for three months or longer, despite treatment.
evolutionarily sinuses are lined with mucous which provide an antibacterial function
Acute sinusitis is nasal congestion with facial pressure for less than 4 weeks. It can be caused by allergies, viruses, bacteria or fungi.
Sinusitis in general affects 1 out of every 7 adults. In most people it resolves spontaneously but in 2% bacterial sinusitis can result. In 80% even this resolves without antibiotics but it can lead to serious complications if a bacterial sinusitis results: chronic osteomyelitis of the frontal bone with Pott’s puffy tumor, cavernous sinus thrombosis or meningitis.
ACUTE SINUSITIS: BACTERIAL AND VIRAL
--15% of aspirates contain viruses
_Acute bacterial sinusitis is 21% H flu, Stretp pneumo 3%, Anaerobes 6%, Staph aureus 4% Strep pyogenes 2% and Moraxella 2%
--Chronic sinusitis- Staph aureus 20%, anaerobes 3%, S pneumo 4%, multiple organisms 16%
pt with Pott’s puffy tumor: osteromyelitis of the frontal bone after bacterial sinus infection. The treatment is surgical.
FUNGAL
Fungal sinusitis can occur in immunocompetent patients or immunocompromised patients
Several types of fungal sinusitis occur.
Mycetoma of the sinus- are the most common forms of fungal sinusitis. They are benign growths of fungal hyphae. Once the fungus ball is removed; no further treatment is indicated. Increased concentrations of manganese can be seen in mycetoma on MRI causing hypointense T2-weighted signal
Manganese is essential in fungal amino acid metabolism. This finding helps distinguish a mycetoma from a tumor.
Allergic fungal sinusitis can cause bone erosion. This is a disease of immunocompetent individuals. The bony erosion can lead to intraorbital or intracranial disease extension and even vision loss due to compression of the optic nerve. This bone erosion regenerates in more than 2/3 of patients with treatment. It is attributed to pressure atrophy by accumulated fungal debris. The treatment is endoscopic sinus surgery.
Invasive fungal sinusitis- Invasive fungal sinusitis is most often Aspergillus and in immunocompromised patients.
patient immunosuppressed because of liver disease who died of a Mucor infection with invasion of the cavernous sinus and bilateral optic nerves. Ischemic infarcts were seen in the frontal lobes and basal ganglia.
Our patient grew Methicillin sensitive Staph . Treatment starts with ampicillin for ten days, followed by augmentin and sulfa can be added . In the case of our patients she had chronic sinusitis with a maxillary antrostomy and daily rinses were suggested.
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Chaudhry A, Hirano S. Fatal rhino-orbito-cerebral mucormycosis in a patient with liver disease, Journal of Am Acad of Derm 2011 volume 65 issue 1:241-43.
Shah K, West C,Simpson J, et al. cutaneous mucormycosis following COVID-19 vaccination in a patient with bullous pemphigoid. Journal of the Am Acad of Derm Open Access June 25, 2021 doi: https://10.1016/j.jdcr.2021.060012
Zinreich S, Kennedy D, Malat J, et al. fungal sinusitis:diagnosis with CT an dMR imaging.. 1988 RSNA Nov 1 https://doi.org/10.11.48/radiology.169.2.3174990.
pt with fungal osteomyelitis treated with dex and antibiotics for covid