Acute Invasive Fungal Rhinosinusitis in a Neutropenic Patient With Thrombocytopenia
46-year-old woman with newly diagnosed acute myeloid leukemia is on day 12 of induction chemotherapy. She has fever 38.7°C, left facial swelling, and orbital pain. Absolute neutrophil count is 0.08 × 10^9/L, platelets 22 × 10^9/L, and serum creatinine 1.4 mg/dL. Nasal endoscopy shows a black eschar on the left inferior turbinate and pale, insensate mucosa. CT reveals opacification of the left maxillary and ethmoid sinuses with erosion of the medial maxillary wall. She is alert but anxious. The oncology team asks whether she can be treated with intravenous antibiotics alone until her counts recover, because her platelets are low and surgery is considered high risk. She has no history of fungal infection and no recent travel. She has already received 3 days of broad-spectrum antibiotics without improvement.
1. What is your immediate diagnostic and therapeutic approach, and why is biopsy essential?
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The combination of neutropenia, fever, facial swelling, orbital pain, and a black eschar is acute invasive fungal rhinosinusitis until proven otherwise; mucormycosis and Aspergillus are the main concerns. Antibiotics alone are inadequate. I would obtain urgent ENT endoscopy with biopsy of the eschar and involved mucosa for frozen section, histopathology, and fungal culture, draw blood cultures and beta-D-glucan/galactomannan as adjuncts, and start liposomal amphotericin B immediately. The oncology team should reverse neutropenia with G-CSF and optimize glucose. Surgical debridement should not wait for culture results because tissue invasion is the diagnostic finding and necrosis limits drug penetration. I would involve ophthalmology if orbital signs progress and coordinate platelet support. The key reasoning is that outcome depends on early debridement plus antifungal therapy plus immune recovery, not on antibiotics.
2. How would you manage surgery with platelets of 22 × 10^9/L, and what determines the extent of debridement?
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With platelets 22 × 10^9/L, I would transfuse platelets to at least 50 × 10^9/L immediately before debridement and check fibrinogen and coagulation. Endoscopic debridement should remove all necrotic tissue until healthy bleeding tissue is reached, including involved turbinate, medial maxillary wall, and ethmoid cells; frozen-section margins can guide resection, but routine radical maxillectomy is not required at the first operation. I would plan re-look debridement every 24–48 hours until no necrosis remains. Orbital exenteration is reserved for extensive orbital invasion not controlled by debridement and antifungals. The low platelet count is a reason to prepare blood products, not to delay source control indefinitely.
3. Which antifungal regimen would you choose, and what monitoring is required?
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Liposomal amphotericin B is first-line because it is less nephrotoxic than conventional amphotericin deoxycholate, especially with creatinine 1.4 mg/dL. I would monitor potassium, magnesium, creatinine, and infusion reactions. Isavuconazole or posaconazole can be used for step-down or salvage, but not as initial monotherapy in a critically neutropenic patient at many centers. Duration is guided by clinical and radiologic resolution plus immune recovery, often weeks to months. I would avoid echinocandins alone for mucormycosis. If cultures grow Aspergillus, voriconazole or isavuconazole may be appropriate, but empiric coverage must include Mucorales until morphology is known.