AN INCIDENTAL FINDING OF ASYMPTOMATIC PULMONARY MUCORMYCOSIS IN A PATIENT WITH DIABETES

Abstract

SESSION TITLE: Pathology Identifying Chest Infections Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Mucormycosis is a rare fungal infection known to present in immunocompromised patients and commonly found in the nasal sinuses. Invasive mucormycosis has previously been described in severely immunocompromised patients such as those with HIV, neutropenia, hematologic malignancy, metastatic cancer, and on chemotherapy. It has been less commonly described in patients with severe uncontrolled diabetes. Here, we present a case of an asymptomatic diabetic patient with an incidental finding of invasive pulmonary mucormycosis.CASE PRESENTATION: A sixty-eight year old east Asian woman with a history of uncontrolled diabetes mellitus presented with dizziness and elevated blood pressure. Her initial vitals showed an oxygen saturation of 75% on room air. She admitted to a non-productive cough. She denied difficulty breathing, dyspnea, or hemoptysis. She denied tobacco use or history of lung disease. She had significant exposure to second-hand smoke over her lifetime from her husband and exposure to pollution and fumes in her youth. Her father died from lung cancer. She denied recent travel, history of incarceration, history of tuberculosis or prior intravenous drug use. Initial chest x-ray showed a dense mass-like consolidation in the left upper lung. CT angiogram of the chest showed a cavitary mass in the suprahilar region of the left upper lobe measuring 3.2 cm x 2.2 cm x 2.9 cm with a mass effect on the left mainstem bronchus causing complete collapse and right hilar lymphadenopathy. Due to concern for malignancy, the patient underwent a bronchoscopy which showed a left upper lobe mass with extrinsic compression of the left mainstem bronchus. Transbronchial biopsy showed mixed inflammatory cells, branching hyphal forms consistent with mucormycosis, necrosis, inflammation and negative for malignancy. She was treated with amphotericin B and then posaconazole.DISCUSSION: This patient had an incidental finding of a left upper lobe lung mass that was confirmed by biopsy to be mucormycosis. Prior literature has described invasive mucormycosis in severely immunocompromised patients such as those with HIV, neutropenia, hematologic malignancy, metastatic cancer, and on chemotherapy. There have been rare cases of mucormycosis in patients with severe uncontrolled diabetes who also have evidence of end-organ damage such as neuropathy, nephropathy, and retinopathy. There are currently no screening guidelines for mucormycosis in any patient population or recommendations for follow up imaging.CONCLUSIONS: While invasive pulmonary mucormycosis has previously been described in critically ill and immunocompromised patients, this case describes an incidental finding of pulmonary mucormycosis in an asymptomatic healthy diabetic patient. Such a case has not been documented in current literature and opens the door for further discussion on screening guidelines and follow up imaging in asymptomatic patients.Reference #1: Walsh TJ, Skiada A, Cornely OA, et al. Development of new strategies for early diagnosis of mucormycosis from bench to bedside. Mycoses. 2014;57 Suppl 3(0 3):2-7. doi:10.1111/myc.12249Reference #2: Jaffer F, Beatty N, Ahmad K. Mucormycosis pulmonary abscess, containment in a patient with uncontrolled diabetes mellitus. BMJ Case Rep. 2017;2017:bcr2016217945. Published 2017 Jan 18. doi:10.1136/bcr-2016-217945DISCLOSURES: No relevant relationships by Bradley CoolidgeNo relevant relationships by Anum Qadri SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Mucormycosis is a rare fungal infection known to present in immunocompromised patients and commonly found in the nasal sinuses. Invasive mucormycosis has previously been described in severely immunocompromised patients such as those with HIV, neutropenia, hematologic malignancy, metastatic cancer, and on chemotherapy. It has been less commonly described in patients with severe uncontrolled diabetes. Here, we present a case of an asymptomatic diabetic patient with an incidental finding of invasive pulmonary mucormycosis. CASE PRESENTATION: A sixty-eight year old east Asian woman with a history of uncontrolled diabetes mellitus presented with dizziness and elevated blood pressure. Her initial vitals showed an oxygen saturation of 75% on room air. She admitted to a non-productive cough. She denied difficulty breathing, dyspnea, or hemoptysis. She denied tobacco use or history of lung disease. She had significant exposure to second-hand smoke over her lifetime from her husband and exposure to pollution and fumes in her youth. Her father died from lung cancer. She denied recent travel, history of incarceration, history of tuberculosis or prior intravenous drug use. Initial chest x-ray showed a dense mass-like consolidation in the left upper lung. CT angiogram of the chest showed a cavitary mass in the suprahilar region of the left upper lobe measuring 3.2 cm x 2.2 cm x 2.9 cm with a mass effect on the left mainstem bronchus causing complete collapse and right hilar lymphadenopathy. Due to concern for malignancy, the patient underwent a bronchoscopy which showed a left upper lobe mass with extrinsic compression of the left mainstem bronchus. Transbronchial biopsy showed mixed inflammatory cells, branching hyphal forms consistent with mucormycosis, necrosis, inflammation and negative for malignancy. She was treated with amphotericin B and then posaconazole. DISCUSSION: This patient had an incidental finding of a left upper lobe lung mass that was confirmed by biopsy to be mucormycosis. Prior literature has described invasive mucormycosis in severely immunocompromised patients such as those with HIV, neutropenia, hematologic malignancy, metastatic cancer, and on chemotherapy. There have been rare cases of mucormycosis in patients with severe uncontrolled diabetes who also have evidence of end-organ damage such as neuropathy, nephropathy, and retinopathy. There are currently no screening guidelines for mucormycosis in any patient population or recommendations for follow up imaging. CONCLUSIONS: While invasive pulmonary mucormycosis has previously been described in critically ill and immunocompromised patients, this case describes an incidental finding of pulmonary mucormycosis in an asymptomatic healthy diabetic patient. Such a case has not been documented in current literature and opens the door for further discussion on screening guidelines and follow up imaging in asymptomatic patients. Reference #1: Walsh TJ, Skiada A, Cornely OA, et al. Development of new strategies for early diagnosis of mucormycosis from bench to bedside. Mycoses. 2014;57 Suppl 3(0 3):2-7. doi:10.1111/myc.12249 Reference #2: Jaffer F, Beatty N, Ahmad K. Mucormycosis pulmonary abscess, containment in a patient with uncontrolled diabetes mellitus. BMJ Case Rep. 2017;2017:bcr2016217945. Published 2017 Jan 18. doi:10.1136/bcr-2016-217945 DISCLOSURES: No relevant relationships by Bradley Coolidge No relevant relationships by Anum Qadri