2 Jun MR

Today's case was a patient that was admitted with orbital cellulitis.  He had been treated for an eye infection - "pink eye" per his report, with two oral abx for 2 weeks without response.  Significant proptosis was present on the left.  He was an ESRD patient on dialysis with poorly controlled diabetes.  CT revealed significant orbiral cellulitis with bony erosions.  On admission he did not appear to have necrosis or eschar in the oral cavity or nares and he was treated with vancomycin, zosyn, and cipro.  At surgery however he was found to have eschar in the sinuses and pathology revealed aseptate hyphae consistent with mucormycosis.

This NEJM case has lots of similar to this feature, and breaks down fungal sinusitis into acute, subacute, and chronic.  This patent likely fit into the subacute category.

Pearls: 
Bad DKA with rapidly progressive rhinocerebral infection.  Look for eschar and necrosis.

To differentiate orbital cellulitis from preseptal cellulitis you must evaluate for proptosis.  Physical exam is helpful, measurement with a proptometer is better, and CT imaging with orbit protocol is best. 

Mucormycosis is a group of fungal infections (Mucor, Rhizopus, Absidia, others) that produce rapidly developing infections in immunosuppressed hosts (marrow transplant, AML, DKA, high dose steroids).  The only effective antifungal options for thse infections are amphotericin B and posaconazole.

Rapid consultation of ophtho and ENT/facial plastics is key to preserving vision in orbital cellulitis.  Blindness may occur abruptly and is typically not reversible.  Orbital decompression will allow time for antibiotic therapy to be effective in cases of bacterial infection, but invasive fungal disease usualy requires significant debridement.