LUNG MASS: PULMONARY MUCORMYCOSIS IN AN IMMUNOCOMPETENT ADULT DIABETIC

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Mucormycosis is an invasive fungal infection for which the most common manifestation is rhino-orbital-cerebral infection, seen as the presenting feature of diabetes in one fourth of patients.Pulmonary infection is the most common form of mucormycosis in patients with hematologic malignancies and remains the second most common presentation after rhinocerebral infection in diabetics.Upon literature review, there are very few cases reported of isolated pulmonary mucormycosis in a diabetic but otherwise immunocompetent. Here, we present a case of pulmonary mucormycosis in a diabetic without any rhino-orbital involvement or immunocompromise. CASE PRESENTATION: A 76-year-old female with multiple medical comorbidities including diabetes presented for intermittent cough with yellow sputum production, dyspnea, and eight pound unintentional weight loss in six months.She denied any hemoptysis, fevers, chills, recent travel or sick contacts.Social history was significant for poor living conditions at home with dust and mold exposure.Upon presentation, vitals were stable.On exam, she had coarse bibasilar breath sounds with rhonchi in left posterior mid-lower lung fields.She had neutrophilic predominant leukocytosis and chest x-ray which showed new round densities over left lower lung field for which she was started on antibiotics for presumed pneumonia.CT chest without contrast showed 2.9cm spiculated left upper lung mass and 2.5cm cavitary mass in left upper lung.She underwent Bronchoscopy during which a firm, stone-like mass was seen at the orifice of the upper segment of the left upper lobe.Endobronchial biopsy results were negative for malignancy, but consistent with pulmonary mucormycosis, showing acute inflammatory exudate and fibrin with accumulation of large, non-septate hyphae with ninety degree angle branching.Staining with Grocott’s methenamine silver was positive for fungal elements. She was started on Posaconazole and discharged from the hospital one week later. DISCUSSION: Mucormycosis is an opportunistic and fulminating fungal infection that presents as rhinocerebral mucormycosis in 30 to 50% of infected patients.In this case, our diabetic patient presented with isolated pulmonary mucormycosis without rhinocerebral involvement.In a literature review of 212 patients with various forms of mucormycosis, 3.3% (7 patients) of immunocompetent patients from 1978 to 2009 had pulmonary mucormycosis. CONCLUSIONS: A review of 929 cases of Mucormycosis reported malignancy as the most common risk factor, found in about 36% of cases with decreasing incidence of isolated pulmonary involvement in diabetics.It is rare to see persistent nodular opacities along with endobronchial involvement that our patient presented with.Antifungals remain the initial treatment of choice in these patients with surgical options pursued when there are signs of angioinvasion including extensive thrombosis and tissue necrosis. Reference #1: Greenerg RN, Scott LJ, Vaughn HH, Ribes JA. Zygomycosis (mucormycosis): emerging clinical importance and new treatments. Curr Opin Infect Dis 2004; 17:517. Reference #2: Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005; 41:634 Reference #3: Mallis A, Mastronikolis S, Naxakis S, Papadas a. Rhinocerebral mucormycosis: an update. European Review for Medical and Pharmacological Sciences. 2010:14:987-992 Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. DISCLOSURES: No relevant relationships by Hemal Mehta, source=Web Response No relevant relationships by Sylvana Salama, source=Web Response No relevant relationships by Salama Salama, source=Web Response