• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.
"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."
In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.
Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."
• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.
"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."
In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.
A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."
Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."
Dr. Zimmer reported having no financial disclosures.