More than meets the eye: rhino-orbital cerebral mucormycosis with diabetic ketoacidosis presenting as periorbital edema resulting in orbital exenteration and maxillectomy.

Mucormycosis is an invasive fungal infection that can cause acute clinical decompensation and death. The literature demonstrates case fatality rates around 50% with differential clinical courses contingent upon anatomical incursion. Rhino-orbital cerebral mucormycosis represents a rapidly hostile variant with poorer outcomes, warranting prompt recognition, workup, and intervention. It is seldom included in differential diagnoses in those with head and neck pathology within the inpatient setting as diagnostic parsimony and low prevalence lead this entity to be often overlooked. Given the acuity and risk factors involved, considering mucormycosis may be prudent during the assessment of hyperglycemic or immunodeficient patients exhibiting maxillofacial disease. When acquiring histories of presenting illness and performing physical examinations, assessment includes mindfulness of diabetes mellitus, craniofacial lesions, and alertness to clinical deterioration. Given the rising incidence of complicated diabetes mellitus in conjunction with a paucity of mucormycosis reports noting the orbit as the diagnostic harbinger, we report the case of a 59-year-old woman admitted to the critical care setting for diabetic ketoacidosis and altered mental status. Physical examination revealed a swollen orbit, later diagnosed as mucormycosis with associated sino-orbit involvement and cranial nerve deficits warranting urgent and extensive facial debridement.

Acute inflammatory presentation of orbital metastasis from urothelial carcinoma: a case report.

Orbital metastasis of urothelial carcinoma is very rare; only 22 cases have been documented. In this case report, we describe a patient 1 month status post transurethral resection of urothelial carcinoma who presented with a clinical picture suggestive of orbital cellulitis. However, neither broad-spectrum antibiotics nor a subsequent trial of methylprednisolone was effective at relieving the patient's symptoms. CT imaging of the head, chest, abdomen, pelvis, and lower extremity showed no signs of metastatic disease. Six days after presentation, punch biopsy of the mass was performed and confirmed urothelial carcinoma metastatic to the orbit. The patient died 3 months later due to multiple sites of distant metastasis. This case report suggests that a high index of suspicion for orbital metastasis is important for patients with a history of urothelial carcinoma with new and acute onset of ocular symptoms and emphasizes the need for urgent systemic evaluation and treatment.

Correction to: A Rare Presentation of Omental Lymphangioma Masquerading as Malignancy in an Adult Patient.

[This corrects the article on p. e00491 in vol. 7, PMID: 33324710.].

Analyzing National Incidences and Predictors of Open Conversion During Minimally Invasive Partial Nephrectomy for cT1 Renal Masses.

Objectives: To analyze predictors of open conversion during minimally invasive partial nephrectomy (MIPN) for cT1 renal masses. Methods: The National Cancer Database (NCDB) was investigated for kidney cancer patients who underwent partial nephrectomy (PN) between 2010 and 2015. Patients who underwent MIPN were stratified into converted and nonconverted groups. Sociodemographics, facility characteristics, and surgical outcomes were compared between the two groups, and multivariate logistic regression model was fitted to identify independent predictors of open conversion. Results: In total, 54,246 patients underwent PN for kidney cancer during the 6-year period. Of those, 18,994 (35%) were open partial nephrectomies (OPNs) and 35,252 (64%) were MIPN. Overall, 1010 (2.87%) of MIPNs were converted to OPN. There was an increasing utilization of MIPN from 50.35% in 2010 to 74.73% in 2015. Patients who had open conversion had more 30-day readmissions (5.95% vs 3.31%, p < 0.01). On multivariate analysis; high-volume facility (>30 MIPNs/year), year of surgery (2015 vs 2010), and robotic approach predicted a lower likelihood of conversion (odds ratio [OR] 0.52, confidence interval [CI] 0.44-0.62; OR 0.59, CI 0.47-0.73; and OR 0.31, CI 0.27-0.35; respectively, p < 0.001 for all). Conversely, Medicaid (vs private insurance; OR 1.75, CI 1.39-2.19, p < 0.001) and male sex (OR 1.26, CI 1.11-1.44, p < 0.001) were independent predictors of conversion. Conclusions: Open conversion in MIPN occurred in 2.87% of cases. There was an increasing utilization of MIPN associated with decreased conversion rates. Higher volume hospitals and progressing year of surgery were associated with less likelihood of conversion.

A Rare Presentation of Omental Lymphangioma Masquerading as Malignancy in an Adult Patient.

Abdominal lymphangiomas are benign vascular neoplasms of the lymphatic vessels. Most are believed to be congenital, and they rarely present in the abdomen in adults. Omental lymphangiomas, in particular, are especially rare and can masquerade as malignancy, which requires further invasive workup. We report the case of an otherwise healthy man with abdominal discomfort, ascites, and a presentation initially concerning for malignancy. However, imaging and pathologic analyses later elucidated the lesion as an omental lymphangioma requiring different management. Treatment options are either resection or sclerotherapy, and the prognosis is generally excellent.

Prosthetic mitral valve Aspergillus fumigatus endocarditis.

Aspergillus endocarditis is a fatal source of valvular infection with a near 100 % mortality rate if pharmacotherapy and valve-replacement surgery are not initiated swiftly after diagnosis. Complicating its diagnosis is the low yield for growth on standard blood culture and time requirements for molecular diagnostic tools to return a result. Aspergillus endocarditis of the mitral valve presents as valvular vegetations that reduce the caliber of the mitral valve and can cause syncope as in the case of mitral stenosis with subsequent valve failure, left atrial enlargement, and prospective cardiovascular failure. Reports of the management of Aspergillus endocarditis after serial mitral valve replacement are not prominent in the literature. We report the case of a 41-year-old female with previous mitral valve prosthesis who received a second prosthetic mitral valve after a syncopal episode. Vegetations resembling thrombi were noted on transesophageal echocardiogram, diagnosed as Aspergillus fumigatus endocarditis, and successfully treated with antifungal therapy in conjunction with removal of her dysfunctional prosthesis.