A 67-year-old woman with poorly controlled diabetes and rheumatoid arthritis treated with a biologic presents with rapidly worsening unilateral facial pain, fever, and nasal congestion. She reports that the pain has become severe over the past 24 hours and tells you, “This feels worse and different from sinus infections I’ve had before.”
Her vital signs are temperature, 103.1°F; heart rate, 112 beats/min; blood pressure, 104/66 mm Hg; respiratory rate, 22 breaths/min; and SpO₂, 96% on room air. She appears acutely ill. Examination reveals right facial tenderness and swelling with dark crusting and an area of black discoloration along the nasal turbinate
What is the most appropriate next step?
- Refer the patient immediately to the emergency department for emergent evaluation and specialty management.
- Prescribe high-dose amoxicillin/clavulanate and arrange follow-up in 48 to 72 hours.
- Prescribe doxycycline and intranasal corticosteroids.
- Obtain outpatient sinus radiographs before determining disposition.
Click to see the answer
Correct answer: a. Refer the patient immediately to the emergency department for emergent evaluation and specialty management.
Rationale: This patient is immunocompromised because she is taking a biologic medication; therefore, she is at increased risk for acute invasive fungal sinusitis, which is a rare but life-threatening infection. High fever, severe facial pain, rapid progression, and nasal crusting or eschar should prompt immediate hospital evaluation rather than outpatient management.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
