TREATMENT OF RHINOCEREBRAL MUCORMYCOSIS WITH INTRAVENOUS, INTERSTITIAL, AND CEREBROSPINAL-FLUID ADMINISTRATION OF AMPHOTERICIN-B - CASE-REPORT

IMPORTANCE: Rhinocerebral mucormycosis is extremely difficult to treat . Approximately 70% of patients are poorly controlled diabetics, and m any of the remainder are immunocompromised as a consequence of cytotox ic drugs, burn injuries, or end-stage renal disease. Despite standard treatment consisting of surgical debridement and the intravenous admin istration of amphotericin B, rhinocerebral mucormycosis is usually a f atal disease. CLINICAL PRESENTATION: We describe the case of a 16-year -old male patient with juvenile onset diabetes mellitus who presented with fever, right-sided hemiparesis, and dysarthria. Axial view comput ed tomography revealed abscess formation in the left basal ganglia and frontal lobe, which was proven by stereotactic biopsy to contain Rhiz opus oryzae. INTERVENTION: Intravenous administration of amphotericin B (30-280 mg/dose) was begun on the day of admission. On hospital Day 20, after the occurrence of frank abscess formation, the lesion was ag gressively debrided. Despite these therapies, there was neurological d eterioration characterized by the development of hemiplegia and aphasi a. Sequential computed tomographic scans enhanced with contrast medium demonstrated progressively enlarging lesions. Ommaya reservoirs were placed into the abscess cavity and the frontal horn of the contralater al lateral ventricle. The patient was then treated with intracavitary/ interstitial injections of amphotericin B during the course of 80 days and three doses of intraventricular amphotericin B. Clinical and radi ographic improvement was achieved after treatment. Two years after the initial diagnosis, magnetic resonance imaging of the brain showed no evidence of disease and an examination revealed a neurologically intac t and fully functional patient. CONCLUSION: We conclude that with an i nfection as morbid as rhinocerebral mucormycosis, it is advisable to u se surgical debridement and ail available routes for delivering amphot ericin B to infected cerebral parenchyma, which include intravenous, i ntracavitary/interstitial, and cerebrospinal fluid perfusion pathways.