Mindnumbing II

(This is a continuation of the case below).

Astute readers, of course, recognize this as the dreaded mucormycosis. This fungal sinus infection progresses rapidly toward fulminant death. The mortality rate of rhinocerebral mucormycosis is extremely high. When we called ENT for this patient, they wanted a stat MRI scan which showed fungal invasion into the brain. ENT placed the mortality at 100% even with all aggressive treatments. Infectious disease also looked at the case and put the mortality at >95%. Mucormycosis - a disease so rare that I had only thought I'd see it in textbooks - is truly a sobering diagnosis.

With the concern of almost-certain fatality, we held multiple family meetings to try to understand what the patient would have wanted. She would not have wanted her face disfigured, and indeed, the marginal benefit of such a heroic intervention was not worth the cost. Eventually, the patient was made comfort care and with the aid of the palliative care service, we let her go peacefully and quietly.

The real question that came up was whether this was an appropriate transfer and whether there was delay in diagnosis. I felt that the patient was not necessarily stable for transfer; she carried with her a definite surgical indication, and she came from a hospital that had an ENT physician. Then again, I wonder whether the accepting physician at Stanford knew how dire this condition was; when we were told about the patient, we had simply thought she was here for a workup of the brain lesions. Lastly, and closest to my heart, I wonder whether I could have made the diagnosis quicker. When I examined the patient, the worry of necrosis and mucor rhinosinusitis did come up like a nagging thought, but I was loathe to call it and call the surgeons for an emergent evaluation. Did the couple hours I waited before calling ENT make a difference? Most likely it did not as the disease was quite progressed when the patient arrived, but sometimes I worry that I did not do enough.