PULMONARY MUCORMYCOSIS: A RARE CAUSE OF HYDROPNEUMOTHORAX

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mucormycosis is a rare but often fatal fungal infection. These fungi are ubiquitous in nature and most commonly cause rhino-orbital-cerebral infections. Patients who are immunocompromised are at higher risk (1). CASE PRESENTATION: A 76 year-old never-smoker with a medical history significant for type 2 diabetes (HbA1c 5.8%) and Coombs negative hemolytic anemia was admitted with 3 months of progressive dyspnea. She had an associated nonproductive cough for 10 days. She denied fevers, night sweats, chest pain or hemoptysis. Two months prior to presentation, she started prednisone 60 mg daily for hemolytic anemia. Prednisone was slowly tapered to 30 mg daily at the time of presentation. She received one dose of Rituximab due to persistent anemia. Evaluation 2 weeks prior to presentation revealed a right upper lobe, 5 cm cavitary lesion on chest CT. On arrival she was tachycardic (heart rate 110) and tachypneic (respiratory rate 32) without hypoxemia. Labs were notable for a hemoglobin of 9.5 g/dl, WBC of 13.6, and creatinine of 1.85 mg/dl. Chest x-ray showed a loculated right hydropneumothorax. Chest CT showed the right hydropneumothorax with progression of the right upper lobe cavitary lesion. A 14 French pigtail catheter was placed at bedside via ultrasound guidance. Pleural studies demonstrated exudative fluid with negative cytology and cultures. She underwent CT-guided biopsy of the cavitary lesion, which revealed inflammation, necrosis, and numerous broad-ribbon-like, pauci-septate hyphae favoring mucormycosis. IV liposomal amphotericin and posaconazole were initiated. Thoracic surgery declined operative intervention due to her age and comorbidities. She developed respiratory and renal failure and passed away 1 month after presentation. DISCUSSION: This patient developed pulmonary mucormycosis in the setting of glucocorticoid and Rituximab therapy. The diagnosis of mucormycosis can be difficult due to nonspecific symptoms (1) and lack of serologic tests. Commonly used fungal antigen tests such as 1,3-beta-D-glucan are traditionally negative (2). Chest CT findings are nonspecific with the classic halo or reversed halo sign present in only a minority of cases (1). A definitive diagnosis is made with histopathology (1). Successful treatment requires early diagnosis, reversal of predisposing factors, surgical debridement, and prompt initiation of antifungal therapy (3). Liposomal amphotericin is first-line pharmacologic therapy (1); however, antifungal therapy without surgical debridement is unlikely to be successful. CONCLUSIONS: Our patient presented with an unusual case of pulmonary mucormycosis; a high suspicion and histopathology are required to make the diagnosis. CT findings are non-specific and common fungal antigen tests can be negative. Early diagnosis and prompt initiation of antifungal therapy with surgical debridement improves the chance for survival. Reference #1: Farmakiotis D, Kontoyiannis DP. Mucormycoses. Infect Dis Clin North Am 2016; 30:143. Reference #2: Ostrosky-Zeichner L, Alexander BD, Kett DH, et al. Multicenter clinical evaluation of the (1-->3) beta-D-glucan assay as an aid to diagnosis of fungal infections in humans. Clin Infect Dis 2005; 41:654. Reference #3: Spellberg B, Walsh TJ, Kontoyiannis DP, et al. Recent advances in the management of mucormycosis: from bench to bedside. Clin Infect Dis 2009; 48:1743. DISCLOSURES: No relevant relationships by Meghan Hill, source=Web Response author/editior relationship with UpToDate Please note: $5001 - $20000 Added 04/01/2020 by David Midthun, source=Web Response, value=Royalty No relevant relationships by Kelly Pennington, source=Web Response