Posaconazole: An Only Oral First-line Antifungal for Rhinocerebral Mucormycosis

Abstract

Introduction Mucormycosis is a rare opportunistic invasive fungal infection. The most commonly reported form of the disease is rhinocerebral mucormycosis. Early diagnosis of the disease and aggressive medical and surgical intervention prevent the high morbidity and mortality associated with mucormycosis. Case report A 54-year-old diabetic and hypertensive male presented with severe frontal headache and retro-orbital pain of 4 days duration with high-grade fever. On examination, the patient was conscious and oriented with a blood pressure of 210/100 mm Hg. The pupils were anisocoric. Frontal sinus tenderness was present. Anterior rhinoscopy showed deviation of nasal septum to left without edema and nasal mucosal congestion. Eye examination revealed normal vision without any periorbital swelling and normal fundus. Plain axial computed tomography showed soft-tissue density material in sphenoid sinus with focal hyperdense component anteriorly. Cerebrospinal fluid study was negative for meningitis with a normal cerebrospinal fluid pressure. Axial T1-weighted image showed T1 intermediate to high signal soft tissue occluding the sphenoid sinus. Axial T2-weighted image showed T2 high signal soft tissue occluding the sphenoid sinus. Similar signal tissue was seen in the middle and posterior ethmoid air cells on both sides. Axial and coronal postcontrast T1-weighted fat-saturated images showed heterogeneously enhancing soft tissue in sphenoid and ethmoid sinuses. The patient underwent functional endoscopic sinus surgery and tissue sampling, following which antifungal therapy with posaconazole was initiated since biopsy from sinus mucosa was consistent with mucormycosis. The patient responded well to functional endoscopic sinus surgical evacuation of the fungal debris and posaconazole and is doing well on follow-up. Conclusion This report highlights the possibility of occurrence of this rapidly fatal condition even with normal-looking nasal mucosa. High index of suspicion is required to prevent the complications as the course of the disease is very rapid. This case report emphasizes the fact that posaconazole is the only available oral antifungal that can be used as a first-line agent in the management of mucormycosis, even in immunocompromised individuals. How to cite this article Jalal MJA, Fernandez SJ, Thomas RM, Kandathil JC, Menon MK, Kuruttukulam G. Posaconazole: An Only Oral First-line Antifungal for Rhinocerebral Mucormycosis. Clin Rhinol An Int J 2016;9(1):46-49.