To answer a few lingering questions from earlier:
1. Regarding her saddle nose deformity, this has been noted in prior exams documented in the outpatient setting years before her current presentation. However, her daughter did notice it was more prominent over the last 6 months. She previously tested negative for syphilis. She is from the Dominican Republic but has been in the United States for over 15 years.
2. She had received stress dose steroids by this time.
Cardiac surgery was consulted. Based on her imaging and impaired right ventricular function, urgent surgical thrombectomy was recommended. Immediately before the procedure, the patient became febrile and tachycardic. Intra-operatively, no evidence of thrombus was seen in the pulmonary artery. However, the surgery team did notice a “cheesy appearance” of the pulmonic valve concerning for endocarditis. The pulmonic valve was debrided and intra-operative cultures were sent.
Post-procedure, she was started on vancomycin and ceftriaxone empirically. Pathology revealed fungal forms morphologically consistent with Mucor species. Blood culture results remained negative throughout the hospitalization. She was started on amphotericin. The patient was evaluated by ENT and found to have no evidence of fungal invasion of nasal cavity.
Q&A has ended
Ersilia Defilippis, MD
Internal Medicine Resident at Brigham Health
Jennifer Joe, MD
Founder, Medstro; Editor-in-Chief, MedTechBoston; ER & Urgent Care Physician