Pulmonary Mucormycosis Treated Successfully With Isavuconazonium and Surgical Therapy

Abstract

SESSION TITLE: Fungal Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary mucormycosis is a rare but devastating fungal infection typically affecting immunocompromised hosts. Although mucorales can affect any organ, the lungs are the predominant site of infection in solid organ transplant patients.1 They pose a diagnostic and therapeutic challenge; therefore a high index of suspicion is required for early diagnosis and treatment. We report a case of pulmonary mucormycosis presenting as a cavitary lung lesion in a post renal transplant patient. CASE PRESENTATION: A 41 year old African American male with type I diabetes mellitus presented with fever, chills, night sweats, 20 lb weight loss, and dysphagia of one month duration. He had received a cadaveric right renal transplant four months earlier for end stage renal disease secondary to diabetic nephropathy and has been on immunosuppressive therapy. Laboratory tests were negative for Aspergillus Ab, Histoplasma Ab, HIV 1/2 Ab, Quantiferon gold, acid-fast bacilli (AFB) and urine legionella antigen. Glycohemoglobin 9.3%. A CT scan of the chest revealed a 4.8 cm X 4.2 cm dense, thick walled right lower lobe (RLL) cavitary lesion (Fig.1). Fiberoptic bronchoscopy revealed diffuse white plaques in the RLL. Bronchoalveolar lavage (BAL) cultures were negative for Pneumocystis jiroveci, AFB and malignant cells. EGD revealed extensive candida esophagitis. The patient was started on fluconazole for candida esophagitis and presumed candida cavitary pneumonia. Although the dysphagia improved, the shortness of breath worsened requiring readmission to the hospital two weeks later. The patient had a CT-guided fine needle biopsy of the cavitary lesion and histopathology revealed nonseptate hyphae. Cultures confirmed Mucor species. The patient underwent a right lower lobectomy and was placed on isavuconazonium therapy. DISCUSSION: In solid organ transplant recipients, immunosuppressive therapy is a major predisposing factor for mucormycosis. It can present as a focal consolidation, pleural effusion or cavitary lesion. Although BAL and sputum culture can aid diagnosis, definitive diagnosis requires histopathology. Fine needle aspiration cytology (FNAC) is an easy and reliable way of obtaining a diagnostic specimen. The cornerstone of treatment is amphotericin, however isavuconazonium has less nephrotoxicity and is better tolerated.2 CONCLUSIONS: In the diagnosis and management of mucormycosis in immunocompromised hosts, it is important to have a high index of suspicion, obtain a histopathologic specimen and be aware of newer treatment options with safer side effect profiles. Early diagnosis and combined medical and surgical management can be curative. Reference #1: Park BJ, Pappas PG, Wannemuehler KA, et al. Invasive non-Aspergillus mold infections in transplant recipients, United States, 2001-2006. Emerging Infectious Diseases. 2011;17(10):1855-1864. Reference #2: Graves B, Morrissey CO, Wei A, et al. Isavuconazole as salvage therapy for mucormycosis. Medical Mycology Case Reprots. 2016;11:36-39. DISCLOSURE: The following authors have nothing to disclose: Tanveer Hassam No Product/Research Disclosure Information