Successful Treatment of Rhino-Orbital Mucormycosis with Posaconazole after Combination of Surgical Treatment and Amphotericin B

Byung Moon Kim; Keun Hae Kim

doi:10.3341/jkos.2015.56.6.956

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Kim and Kim: Successful Treatment of Rhino-Orbital Mucormycosis with Posaconazole after Combination of Surgical Treatment and Amphotericin B

Original Article

J Korean Ophthalmol Soc 2015;56(6):956-960.

Published online: 7 September 2015

DOI: https://doi.org/10.3341/jkos.2015.56.6.956

Successful Treatment of Rhino-Orbital Mucormycosis with Posaconazole after Combination of Surgical Treatment and Amphotericin B

Byung Moon Kim, MD, Keun Hae Kim, MD, PhD

Department of Ophthalmology, Catholic University of Daegu School of Medicine, Daegu, Korea

Address reprint requests to Keun Hae Kim, MD, PhD Department of Ophthalmology, Daegu Catholic University Medical Center, #33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea, Tel: 82-53-650-4148, Fax: 82-53-627-0133 E-mail: kimkh@cu.ac.kr

Received 6 February 20157 May 2015 Accepted 12 May 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report a case of rhino-orbital mucormycosis successfully treated by posaconazole salvage therapy after a surgical intervention combined with amphotericin B treatment.

Case summary

A 57-year-old female with uncontrolled diabetes mellitus presented to our department with left periorbital swel-ling and pain for 3 days. At initial presentation, complete ptosis, complete external ophthalmoplegia, and exophthalmos of 6 mm were observed in the left eye. Pupillary reflex was absent in the left eye. Orbital magnetic resonance imaging showed left focal maxillary sinusitis and left posterior orbital inflammatory infiltration with left optic nerve involvement. Nasal endoscopic examination showed black eschar in both nasal cavities. Histopathological examination of the involved nasal cavities showed non-sep-tated fungal hyphae with blunt-angle branching, thus rhino-orbital mucormycosis was diagnosed. The patient underwent a lid-sparing subtotal exenteration, wide endonasal debridement of the nasal necrotic tissues, and intravenous injections of amphotericin B for 7 weeks. The patient continued to receive oral posaconazole salvage therapy for 6 months and was successfully treated. At the 44-month follow-up, recurrence was not observed, and the patient is wearing a new type of silicone oculofacial prosthesis.

Conclusions

Rhino-orbital mucormycosis is an aggressive, opportunistic fungal infection that is life-threatening despite ex-enteration and amphotericin B treatment. Sequential use of oral posaconazole as salvage therapy may be helpful for a successful treatment.

Keywords: Mucormycosis, Oculofacial prosthesis, Posaconazole, Salvage therapy

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Figure 1.

Nine-cardinal photographs at the first visit showing total ophthalmoplegia and conjunctival chemosis of the left eye.

Figure 2.

Postcontrast (A) axial and (B) coronal orbital magnetic resonance imaging (MRI) demonstrated heterogenous enhancement of the left posterior orbit and the left maxillary sinusitis.

Figure 3.

Nasal endoscopic photograph showing the black eschar.

Figure 4.

Microscopic examination showing the wide non-septated hyphae with obtuse angle branching with in the neuronal tissue (Periodic acid Schiff [PAS], ×100) (A) and the vessel (Gomori-methanamine silver stain, ×400) (B).

Figure 5.

Postoperative external photograph wearing a new oculofacial prosthesis with good cosmetic result.

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