Invasive Broncho-Pulmonary Mucormycosis (IBPM) Misdiagnosed as Tuberculosis

Shital Patil,Rajesh Patil

doi:10.29333/ejmds/11562

Abstract

Hemoptysis is nonspecific respiratory symptom with variable etiological factors ranging from infections like tuberculosis, pneumonia, fungal infections to malignant lung process. Although Tuberculosis is leading cause of hemoptysis and reason for empirical treatment and delay in diagnosis, computerized tomography and fiberoptic bronchoscopy has made real change towards approach in management of these cases presented with nonspecific symptoms. In this case report, we have documented ‘invasive bronchopulmonary Mucormycosis’ as cause of recurrent hemoptysis and persistent pulmonary opacity on chest radiograph irrespective of best possible conventional treatment including higher antibiotics and blanket cover of anti-tuberculosis treatment for 4 months. We have documented ‘Reverse halo sign’ on chest CT imaging and final diagnosis established with Bronchoscopy guided lung biopsy showing ‘presence of fungal infection causing extensive parenchymal necrosis, angioinvasion and cartilage destruction along with bronchiolar invasion.’ Caution should be taken during biopsy of these hypervascular lesions as propensity to have post-biopsy ‘catastrophic massive hemoptysis.’ We have also documented near total complete resolution of airway and lung lesions to medical management including Amphotericin and Posaconazole.

Highlights

Mucormycosis is a rare opportunistic fungal infection
Clinical diagnosis is difficult in pulmonary mucormycosis, and early diagnosis is needed for this lifethreatening infection [6]
We have documented empirical anti-tuberculosis is an absolute option and bronchoscopy has very crucial role in diagnosing unexplained hemoptysis and bronchoscopy guided techniques will be crucial during entire course of illness from diagnosis to management of pulmonary Mucormycosis cases

Summary

INTRODUCTION

Mucormycosis is a rare opportunistic fungal infection. It derives its name from the Mucorales order of filamentous fungi and family Mucoraceae. 43-year male, driver by occupation, alcohol and tobacco addict, newly diagnosed uncontrolled diabetes mellitus, presented with history of recurrent hemoptysis, dry cough since 4 months, received antituberculosis treatment at general physician center with Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide for first 2 months and Isoniazid, Rifampicin, and Ethambutol for 2 months He was diagnosed as pulmonary tuberculosis on basis of chest x-ray and sputum examination was inconclusive and sputum gene Xpert MTB/RIF were negative done by general physician. His first chest x-ray done at general physician center was showing right upper lobe inhomogeneous opacification (Figure 1) He was admitted there, investigated as sputum microscopy for acid fast bacilli and sputum Gene Xpert MTB/RIF and results were inconclusive and negative for mycobacterium tuberculosis genome. The patient was discharged on oral Posaconazole tablet 300 mg daily for 12 weeks and we have monitored renal functions monthly and pulmonary lesions were clearly followed till 12 weeks

DISCUSSION

CONCLUSIONS