The patient was a 39-year-old man who was referred to our hospital because of headache, cough, and hemoptysis. The patient is a known case of WG for 2.5 years. His other complains were fever and chills. Dark bloody nasal discharge was also mentioned.
Headache was localized on frontal and maxillary sinuses. It was permanent and not related to light and noise. In the frontal region, a pulsatile fashion was described. No exacerbating factor was mentioned. We found no nausea or vomiting history during those days.
Firstly, there were bloody streams in sputum; however it changed to apparent hemoptysis in a few days. It occurred two times and was estimated about 200 cc each time.
He had no previous history of smoking, addiction, any specific allergy, hypertention, diabetes mellitus, or hyperlipidemia. He afflicted a chronic anemia and admitted for pneumonia last year. Vaccination seems to be complete. No history of tuberculosis or any similar problem in the first-degree relatives had been recorded before.
He received cyclophosphamide (100 mg BID), methyl prednisolone (50 mg QID), ceftriaxon (1 g BID), and azithromycine (250 mg per day). Two units of packed cells were administered after his last episode of hemoptysis.
During his stay, he was conscious and obey, a little pale, and had mild coughing without any toxicity. He complained of blurred vision in eyes, nasal stiffness, rhinorrhagi, hearing loss, hematuria, perspiration, artheralgia in wrist and foot.
On the examination of neck mobile, not firm, elastic lymph nodes was palpable. He had a saddle nose and septal perforation with many dark crusts was obvious in nasal examination.
There was redness in his right eye. Vision and pupil reflex were normal; ophthalmologic examination revealed no ophthamologic involvement.
In chest examination crackles in the upper part of lungs, and generalized expiratory wheezing was heard. Other physical examination revealed no abnormal findings. Spiral-computed tomography (CT) with contrast from the chest revealed multiple cavitary lesions with alveolar infiltration.
In coronal sinus CT scan, a bilateral mucosal thickening in frontal, sphenoidal, ethmoidal, and maxillary sinuses was present. Bony erosion of the medial wall of both maxillary sinuses and nasal septum was seen [Figure 1].
His laboratory data contained WBC: 12000 (NEUT: 79%); hemoglobine: 9.1; urine sediment: RBC+, WBC+, WBC cast, granuler cast; C-ANCA was positive(1/40).
As the patient had complained of hearing loss, a pure tone audiometry was done that showed left conductive hearing loss (40 db, air bone gap).
A biopsy of the nasal septum with culture of crusts was done by the otolaryngologist. Nasal examination revealed necrotic materials [Figure 2]. The specimen was ready in 1 week; during this time the patient became ill, altered mental status, and drowsy.
Pathology and culture revealed a necrotic material with nonseptated fungal hyphae, consistent with mucormycosis [Figures 3a and b], so amphotricine was administered immediately and an endoscopic sinus surgery (ESS) was done to accomplish the diagnosis and treatment. Massive necrotic fungal debris in his maxillary and ethmoid sinuses was brought out completely. The Eustachian tube was eroded in the left side (that justified his unilateral conductive hearing loss).
Immediately after clinical and pathologic establishment of diagnosis of mucormycosis, prednisolone was tapered and administration of cyclophosphamide was stopped. On the other hand, intravenous immune globulin (IVIG) was started (2.5 g for 5 days). Besides, he was also taken vancomycine (500 mg BID), amphotricine (30 mg per day), tab coterimoxazole, tab acid folic, and atrovent spray.
His cough and headache became better. The patient's mental status improved, and he did not remind any visits or surgery in 2 weeks before. He experienced a second sinus examination by endoscopic sinus surgery. He had complete remission of his fungal infection. Six-week administration of amphotericine was accomplished. At the time of discharge he complained of mild bilateral blurred vision and left conductive hearing loss.