A RARE FATAL CASE OF DISSEMINATED MUCORMYCOSIS IN AN IMMUNOCOMPETENT PATIENT DIAGNOSED ON AUTOPSY

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We present a fatal case of undiagnosed disseminated mucormycosis in an immunocompetent patient that was diagnosed on autopsy. CASE PRESENTATION: 63-year-old male with history of deep vein thrombosis/pulmonary embolism on apixaban, atrial fibrillation, hypertension and morbid obesity presented with fever, abdominal rash and malaise for 3 days. He was discharged from the ED on oral doxycycline for possible Lyme disease. Patient had worsening generalized weakness and diarrhea and presented to the ED again two days later febrile, hypotensive and tachycardic. Labs were remarkable for white cell count of 19,800 and lactic acid of 4.3 mmol/L. He was started on broad-spectrum antibiotics: piperacillin-tazobactam, vancomycin and doxycycline. Patient’s condition significantly worsened with multiorgan failure and he was started on continuous renal replacement therapy. He was placed on four inotropic agents and was started on intravenous bicarbonate infusion in the setting of severe metabolic acidosis. The patient was intubated and mechanically ventilated. Procalcitonin level was found to be 26. Serologies for Rocky Mountain spotted fever, babesiosis, anaplasmosis and ehrlichiosis were negative. Respiratory pathogen panel, hepatitis panel, EBV IgM, CMV IgM, monospot test and leptospirosis antibody, anti-double stranded DNA, anti-citrullinated peptide, anti-histone antibody, anti-neutrophilic cytoplasmic antibody were all negative. Patient had some initial improvement and was weaned off the ventilator and vasopressors. Antibiotics were discontinued after 14 days. Unfortunately, however, patient became pulseless during dialysis and was reintubated. He simultaneously began to decompensate, and vasopressors were reinitiated. IV vancomycin, cefepime, metronidazole, and acyclovir were started with suspicion for disseminated Herpes Simplex infection due to new facial eschars as shown in figure 1. Repeat CT abdomen showed progressive pancreatitis, with normal lipase levels. Patient again went into cardiac arrest. After resuscitation, however, he was found to have a bowel perforation with repeat blood cultures growing Bacteroides thetaiotaomicron. He subsequently passed away within a day. Postmortem autopsy showed disseminated mucormycosis with extensive necrosis involving lungs, spleen, bowel, kidneys as shown in figures 2 and 3. DISCUSSION: Disseminated mucormycosis is a rare fungal infection with the mortality rate of approximately 100%. It rarely occurs in immunocompetent individuals(1). The only hope for treatment is rapid diagnosis, correction of predisposing factors, surgical debridement of necrotic tissue and antifungal therapy. (2) CONCLUSIONS: Our patient, who initially presented with nonspecific symptoms, eventually progressed to refractory shock, unresponsive to broad spectrum antibiotics. The suspicion for disseminated mucormycosis should not be confined to immunocompromised patients. Reference #1: Horger M, Hebart H, Schimmel H, Vogel M, Brodoefel H, Oechsle K, et al. Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation. Br J Radiol. 2006;79:e88–95. Reference #2: Amir Hossein Sarrami, Mehrdad Setareh,1 Masoud Izadinejad,1 Noushin Afshar-Moghaddam,2 Mohammad Mehdi Baradaran-Mahdavi,3 and Mohsen Meidani4. Fatal Disseminated Mucormycosis in an Immunocompotent Patient: A Case Report and Literature Review. Int J Prev Med. 2013 Dec; 4(12): 1468–1471. DISCLOSURES: No relevant relationships by Marc Filstein, source=Web Response No relevant relationships by Fizza Hirani, source=Web Response no disclosure on file for Rameez Phulphoto; No relevant relationships by Emily Zagorski, source=Web Response