Arthrographis Kalrae Masquerading as a Pulmonary Nodule After Breast Irradiation

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The genus Arthrographis is a mold usually isolated from soil and decaying vegetation. The genus is consisted of 5 species. It is an extremely rare cause of human disease and usually affects immunocompromised hosts. There have been only 11 reported cases in the literature since first described in 1976. Their role in human disease is still not completely clear. To our knowledge, this is the first reported case of solitary pulmonary nodule due to A kalrae infection. CASE PRESENTATION: An 80 year old past smoker female was referred to pulmonary clinic for evaluation of enlarging right upper lobe (RUL) ground glass opacity (GGO). She had a past history of breast cancer and underwent left sided lumpectomy with axillary dissection and radiation therapy in 2007. She had a chest CT in 2012 for evaluation of chronic cough and was noted to have a 1.1cm GGO in the RUL. In 2015, her breast cancer recurred at the previous lumpectomy site and during further evaluation the GGO was noted to have increased to 2.4cm. She underwent local resection. CT guided lung biopsy was non diagnostic. In the clinic, she complained of chronic cough but denied any fever, night sweats, weight loss, sputum production or shortness of breath. Physical exam and laboratory evaluation was unremarkable. A PET-CT showed 2.4cm hypermetabolic RUL GGO. She underwent navigational bronchoscopy with biopsy. The biopsies revealed reactive bronchial cells but no malignant cells. Initial cultures were negative. Fungal culture came back positive for Arthrographis kalrae. DISCUSSION: A kalrae is the most commonly isolated species from clinical specimens. They have been described to cause keratitis,opthalmitis, sinusitis, meningitis, cerebral vasculitis, endocarditis, mycetoma of the hand, onychomycosis, endocarditis and lung abscess. The route of entry is either the respiratory tract or direct inoculation into the skin and subcutaneous tissue. Specific risk factors or this rare fungalinfection are yet to be identified. Radiation therapy to the chest is suspected to be a risk factor for pulmonary infection with this organism. Terbinafine seems to be the best anti-fungal agentavailable. The azoles are also effective. Amphotericin seems to have some effect but the echinocandins are ineffective. CONCLUSIONS: Arthrographis kalrae is an unusual human pathogen and rarely considered in the differential diagnosis. With the ever growing number of immunosuppressant medications, whether this organism will become a potential threat is uncertain. The role of the organism in pathogenesis is human disease also needs further elucidation. Reference #1: Biser S. A, Perry H. D, Donnenfeld E. D, Doshi S. J. & Chaturvedi V. (2004). Arthrographis keratitis mimicking acanthamoeba keratitis. Cornea 23, 314-317. DISCLOSURE: The following authors have nothing to disclose: Biplab Saha, Himani Sharma, Kristin Fless, Paul Yodice, Fariborz Rezai, Nirav Mistry, Vagram Ovnanian No Product/Research Disclosure Information