수술적 치료와 암포테리신 병용요법 후 포사코나졸로 완치된 비안와형 뮤코르진균증
Successful Treatment of Rhino-Orbital Mucormycosis with Posaconazole after Combination of Surgical Treatment and Amphotericin B
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목적: 수술적 치료와 암포테리신 B 병용요법 후 포사코나졸 구제요법으로 완치된 비안와형 뮤코르진균증 1예를 경험하였기에 보고하고자 한다. 증례요약: 조절되지 않는 당뇨병이 있는 57세 여자 환자가 3일 동안 좌측 안와 주위에 부종과 통증이 있어서 안과에 의뢰되었다. 내원당시 좌안은 완전 눈꺼풀처짐, 전체 눈근육마비 소견과 함께 6 mm 안구돌출이 있었으며, 동공빛반사가 전혀 없는 상태였다. 안와자기공명영상에서 국소적인 좌측 위턱굴염과 함께 좌측 뒤쪽 안와의 염증이 좌측 시신경을 침범한 소견이 관찰되었다. 코내시경 검사상 양측 비강 내 검은 괴사딱지가 관찰되었다. 비강 내 병변에 대한 조직학적 검사상 격막이 없고 둔각을 이루며 가지를 치는 균사가관찰되어 비안와형 뮤코르진균증으로 진단되었다. 좌측 눈꺼풀 보존 부분 안와내용제거술 및 코안 괴사조직의 광범위한 내시경하제거술을 받았고 암포테리신 B 정맥주사를 7주간 시행한 후 경구 포사코나졸 구제요법을 6개월간 받았으며, 이후 완치되었다. 치료후 44개월째 재발 소견은 없으며, 새로운 형태의 실리콘 눈얼굴보형물을 착용하고 있다. 결론: 비안와형 뮤코르진균증은 공격적인 진균 기회감염증으로 안와내용제거술과 암포테리신 B로 치료해도 사망률이 높은 질환이다. 이때 경구용 포사코나졸을 구제요법으로 연달아서 사용하는 것이 병의 완치에 도움이 될 수 있을 것으로 보인다.
Abstract
Purpose: To report a case of rhino-orbital mucormycosis successfully treated by posaconazole salvage therapy after a surgical intervention combined with amphotericin B treatment. Case summary: A 57-year-old female with uncontrolled diabetes mellitus presented to our department with left periorbital swelling and pain for 3 days. At initial presentation, complete ptosis, complete external ophthalmoplegia, and exophthalmos of 6 mm were observed in the left eye. Pupillary reflex was absent in the left eye. Orbital magnetic resonance imaging showed left focal maxillary sinusitis and left posterior orbital inflammatory infiltration with left optic nerve involvement. Nasal endoscopic examination showed black eschar in both nasal cavities. Histopathological examination of the involved nasal cavities showed non-septated fungal hyphae with blunt-angle branching, thus rhino-orbital mucormycosis was diagnosed. The patient underwent a lid-sparing subtotal exenteration, wide endonasal debridement of the nasal necrotic tissues, and intravenous injections of amphotericin B for 7 weeks. The patient continued to receive oral posaconazole salvage therapy for 6 months and was successfully treated. At the 44-month follow-up, recurrence was not observed, and the patient is wearing a new type of silicone oculofacial prosthesis. Conclusions: Rhino-orbital mucormycosis is an aggressive, opportunistic fungal infection that is life-threatening despite exenteration and amphotericin B treatment. Sequential use of oral posaconazole as salvage therapy may be helpful for a successful treatment.
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