A 44-year-old man with a history of poorly controlled type 2 diabetes mellitus was referred to our hospital for a 2-month history of severe refractory left facial pain.
Periodontitis was initially treated with extraction of left upper molar and oral antibiotic therapy.
a Left perisinusitis torpidly, with left facial paralysis, severe pain, edema and epistaxis, so a computed axial tomography (CAT) of facial mass was performed, which showed inflammatory paninus
He was hospitalized to complete a study with MRI, showing extensive inflammatory involvement of superficial soft tissues and deep left craniofacial, with extension through the sinus branches of the trigeminal nerve, collection of f
Surgical removal was performed and intravenous antibiotic therapy was initiated with ceftriaxone and clindamycin for 10 days.
The control MRI showed progression of the inflammatory process.
A new silk was performed finding necrotic tissue and purulent secretion at the maxillary level.
A rapid biopsy was taken, which revealed necrotic tissue and granulomas. A complete microbiological study was also performed to identify the bacteria.
On admission, mucormycosis was diagnosed and treated with liposomal amphotericin B 5 mg/kg/day, associated with vancomycin 1 g c/8h and imipenem 500 mg every 6 h.
Cultures negative (current, bacillus and Koch), universal and negative polymerase chain reaction (PCR), HIV negative, glucan negative, and beta-D-glucan negative were reported.
A third surgical procedure was performed and new biopsies were taken, showing chronic active granulomatous inflammatory process. No hyphae were found.
Complete blood count showed positivity in the three series and both histology and immunohistochemical study were negative for the presence of nasal T/NK cell lymphoma.
Neither was the histology consistent with the presence of sarcoidosis and both levels of angiotensin converting enzyme (ACE) and vitamin D were normal.
After suspicion of GPA, treatment was initiated with methylprednisolone 250 mg daily intravenous for 3 days and then oral prednisone 1 mg/kg/day.
The chest CT ruled out pulmonary nodules and cavitations.
The immunological study was negative for ANCA by IFI and ELISA (PR3 and MPO).
There was also no evidence of vasculitis in other organs; normal renal function with non-inflammatory urine sediment, absence of skin lesions and peripheral nervous system.
Although the patient had multiple occasions denied the use of drugs, it was made in the pre-initiation of cyclophosphamide, explaining the risks of cocaine abuse, which is why polymedication insists on cocaine abuse.
With the diagnosis of CIMDL, a rapid reduction in the prednisone dose was planned and support was requested from the Psychiatry team.
