Case of Week 감염면역 내과 Prof. 이미숙 / R2 이윤정

Chief complaint Rt. Facial pain onset) 내원 10 일전 Present illness 특별한 medical Hx. 와 약물 복용력 없는 63 세 여자 환자로 내원 10 일전부터 생긴 지속적인 Rt. Facial pain 으로 건국대 병원에서 검사 상 특이소견 보이지 않았으나, 증상 지속되어 본원 응급실 경유하여 신경과로 입원함. ( 건국대 병원 Brain MRI : Sphenoid sinusitis 외에 특이 소견없음 ) Patient’s history 김 0 자 (F/63) Adm

Medical history DM/HTN/TB/Hepatitis ( -/ -/ - /- ) OP Hx. (- ), 여행력 (-) Family history Unremarkable Personal history Alcohol (-), Smoking(-) Occupation : 주부 Patient’s history

 General : fatigue(-) fever(-) chills(-) sweat(-) weight loss(-)  Head & Neck : headache(-) trauma(-) Ext. wound (-) stiiffness(-) Rt. Facial pain (+): trigerminal area( V2, V3 ara), lancinating pain, continuous, Rt.facial edema (-) heatness(-)  Eye & ENT : sore throat(-) gingival swelling(-) rinorrhea (-) post nasal drip (-) visual disturbance(-),diplopia (-)  Respiratory : cough(-) sputum(-) hemoptysis(-)  Cardiac : chest pain(-) dyspnea(-) palpitation(-)  Gastrointestinal : A/N/V/D/C(-/-/-/-/-) abdomial pain (-)  Neurology : dizziness(-) tremor(-) syncope (-) Review of System

Physical Examination  V/S : 110/60 mmHg-84 회 /min-20 회 /min-36.3°C  General apperance Mental : alert Acutely ill appearance  Skin no rash or pigmentation  Head & Neck no thyroid gland enlargement no neck vein engoregement no thyroid gland enlargement Rt. Facial tenderness (-) Rt. Facial tenderness (-)  Eye & ENT isocoric pupil with PLR(++/++), EOM : full without nystagmus pinkish conjunctiva not icteric sclera Physical Examination

 Thorax symmetric chest expansion clear breathing sound without rale regular heart beat without murmur  Abdomen soft and flat abdomen normoactive bowel sound no hepatosplenomegaly  Back / Extremity pretibial pitting edema(-/-)  Neurologic examination babinsky (-/-), unremarkable finding Physical Examination

Chest x-ray

 CBC/DC 5990/mm g/dL % /mm 3 (seg.:65.4%) INR :1.08 % a-PTT : 42 C 33 sec  Chemistry TB/DB 0.8 / 0.3 mg/dL AST/ALT 18 / 10 IU/L ALP / rGT 97 / 12 IU/L Prot/Alb 6.9 / 3.2 g/dL Glucose 105 mg/dL BUN/Cr 8 / 0.5 mg/dL Na/K/Cl 137 / 3.9 / 101 mmol/L Ca/P/ Mg 9.4 / 3.7 / 3.2 mg/dL ( / / ) CRP 3.4 mg/dl ( < 0.5 )  U/A RBC 0-1 /HPF, WBC 2-4 /HPF Initial Lab Finding ( )

 Trigerminal neuralgia  Pain control, Steroid Tx. 고려  Pain 호전 되지 않을 경우 OP (microvascular decompression) 고려 Impression & Plan

Trigerminal neuralgia Gabapetin 300mg,tid.po Carbamazepine 50mg,bid,p.o Tramadol 50mg,tid.p.o Prednisolone p.o 30mg ( 아침 ), 10mg( 저녁 ) 시작하여 점차 감량함 H/D D4 ~ D26 ( ~9.20) Pain 은 호전되지 않고 drug side effect 로 nausea,vomitimg, poor oral intake 보임, intractable trigerminal neuralgia 로 op 고려하기로 함

 Rt. Periorbital, perinasal, frontal area 에 새롭게 dull pain 발생함, nasal obstruction (+), fever (-)  PNS CT 시행함 H/D D27~D31 ( ~9.25)

PNS CT (09.20)

 ENT 에서 Express Bx. 시행함 (fungal infection )  Amphotericin B 시작함  endoscopic exploration and removal of fungal material Bx :Anterior and posterior, ethmoid sinus, excision: Acute and chronic inflammation with aspergillosis Paranasal sinus, posterior, ethmoid sinus, excision: Aspergilloma Paranasal sinus, sphenoid sinus, excision: Aspergilloma  감염내과로 전과됨 H/D D27~D31 ( ~9.25)

 부터 Rt. Eye 의 시력저하, diplopia (+) nystagmus (-), ptosis Rt. (+) : 눈이 위로 잘 안떠지는 증상 보임  PNS CT : Bulging contour of right cavernous sinus  Brain MRI : Invasion of optic foramen and orbital apex  안과 consult 에서 cranial nerve II,III,VI injury 로 Rt.eye EOM 의 장애  Rt.eye 적출술 필요하나 환자, 보호자 refuse 함 H/D D36~D48 ( ~10.12)

PNS CT (10.07)

BRIAN MRI (10.12) & PNS CT (11.20)

차 endoscopic exploration and removal of fungal material 시행 Pain 감소, F/U PNS CT 시행 Rt.facial pain 감소, anorexia,nausea,poor oral intake 호전되어 ictraconazole 200mg,bid,po 로 퇴원함 H/D D78~ 퇴원 ( ~12.13)

증상 악화 PO change Total dose : 3.5g LFT F/U Liposomal amphotericin B 5mg/kg,qd,iv Caspofungin 50mg, qd, iv Ictraconazole 200mg,bid,p.o Amphotericin B 09.22~ ~10.17 Nausea,vomiting anorexia ~ ~12.13 Anti-fugal agent 치료경과

 OPD F/U 시에는 Ictraconazole 200mg,bid.p.o 로 계속 유지 하고 있음  OPD F/U 시에는 AST/ALT 85/36 로 상승 소견 보여 ictraconazole stop 함 OPD F/U

 Rhino-orbito-cerebral aspergillosis Final diagnosis