Conclusion and Results
Based on these results the diagnosis of concomitant probable invasiveAspergillus rhinosinusitis and confirmed invasive Mucor rhinosinusitis with concomitant probable invasive pulmonary aspergillosis (IPA) and probable pulmonary mucormycosis was made. After 7 days of therapy the patient underwent sinuses endoscopy for second look and no evidence of necrosis was reported. Meropenem, ciprofloxacin, and vancomycin were stopped and treatment based on liposomal amphotericin B was continued\RL. He was afebrile on day 5 of treatment.
Repeated lung HRCT showed a slight reduction in the size and number of the nodular lesions after 22 days of antifungal therapy. According to the patient’s need to start consolidation chemotherapy, high dose methotrexate with leucovorin and ara-C regimen was started after 22 days from the start of liposomal amphotericin B.
The patient underwent 4 ENT consults and no evidence of necrosis was reported in endoscopies. The lung HRCT revealed significant improvement and after 37 days the liposomal amphotericin B was overlapped with posaconazole suspension 200 mg every 6 hr for 5 days and then liposomal amphotericin B was discontinued. The posaconazole suspension was continued with this therapeutic dose for 30 days. At the time of writing this paper, 5 months follow-up demonstrated no evidence of infection recurrence and the courses of chemotherapies are continued under posaconazole secondary prophylaxis. The timeline of the patient treatment was showed in [Figure 7] .
This case report highlights the implication of considering the sinopulmonary Aspergilosis and mucor mycosis coinfection in a patient with acute leukemia as there are not so many cases described in the literature.
The keys to optimize the management of these coinfectional situations include a high index of suspicion for the disease with early detection of the signs and symptoms by a multidisciplinary approach, rational antifungal therapy and if necessary, aggressive surgical resection.
As there is no evident consensus concerning the therapy in mixed fungal-infections, more potent and focused line of treatment as compared to infection with a single fungal agent will be required.