Correspondence

Case 9-2002: Orbital Mucormycosis

N Engl J Med 2002; 347:855-856September 12, 2002

Article

To the Editor:

In Case 9-2002 (March 21 issue),1 the patient's pancytopenia and subsequent splenectomy may have been considered risk factors for the development of mucormycosis, but the nasal packing also may have played a part in promoting the extension of the infection from the nasal passages to the preseptal spaces and beyond. How long was the packing in place, and was it anterior or posterior?

Tristram C. Dammin, M.D.
Lahey Clinic, Burlington, MA 01805
drtcd@massmed.org

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 9-2002). N Engl J Med 2002;346:924-929
   Full Text | Web of Science | Medline

To the Editor:

Although Dr. Bienfang arrived at the correct diagnosis, he did not relate this unusual infection to the patient's splenectomy only 16 days before the onset of eye symptoms. The spleen has a well-recognized and important role in the prevention of infection, and infection with unusual organisms may certainly occur after splenectomy or in patients with congenital asplenia.

Gordon J. Gilbert, M.D.
500 Pasadena Ave. S., St. Petersburg, FL 33707

To the Editor:

This case report deals with “rapid development of ocular arterial disease.” Should not the differential diagnosis include cholesterol embolization?1

Carl F. Needles, M.D.
1955 Merrick Rd., Merrick, NY 11566

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 2-1991). N Engl J Med 1991;324:113-120
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Bienfang and a colleague reply:

To the Editor: Drs. Dammin and Gilbert address important considerations that were neglected in the discussion, which emphasized the level of iron in tissue. Both correspondents ask why this nondiabetic but obviously very ill woman fell prey to a mucormycosis infection. It is difficult to invoke either the pancytopenia or the splenectomy as a risk factor. The patient's hematologic values while she was ill showed an ability to mount a fairly robust white-cell response to the infection. Although the spleen is important in complement-based reactions, trapping blood-borne foreign intruders and responding with an immune response to non-novel infections (all features of bacterial infections), it is not thought to have much of a role in combating encapsulated organisms such as fungi.

More challenging is the question of the nasal packing. Mucorales are molds. There certainly are cases of mucormycosis, also known as zygomycosis, attributed to surgical dressings.1,2 In this case, retained nasal packing was indeed found at the time of surgery. Considering, however, how commonly nasal packing is performed and how rarely cases such as this one are seen, we think this patient must have had some other susceptibility factor that was never identified.

One of the many roles of the Clinicopathological Conferences is to emphasize the diagnostic importance of a particular clinical finding in the context of a patient's particular illness. In this instance, the arterial occlusion in an obvious case of sinus and orbital sepsis without severe orbital compression essentially reduced the diagnostic considerations to one: mucormycosis. The discussion emphasized how the arterial occlusion narrowed the diagnostic considerations. Dr. Needles is, of course, correct in suggesting that there are legions of local and systemic causes for arterial occlusion, including cholesterol embolization. In this case, the patient's carotid arteries and heart valves were already under close scrutiny because of her previous illnesses, and she was receiving an anticoagulant. The failure to expand the differential diagnosis of the arterial occlusion was due to a desire to make an uncluttered point and to avoid pedantry.

Don C. Bienfang, M.D.
Mark Varvares, M.D.
Harvard Medical School, Boston, MA 02115

2 References

1. 1

   Dennis JE, Rhodes KH, Cooney DR, Roberts GD. Nosocomial Rhizopus infection (zygomycosis) in children. J Pediatr 1980;96:824-828
   CrossRef | Web of Science | Medline

2. 2

   Mead JH, Lupton GP, Dillavou CL, Odom RB. Cutaneous Rhizopus infection: occurrence as a postoperative complication associated with an elasticized adhesive dressing. JAMA 1979;242:272-274
   CrossRef | Web of Science | Medline