Successful Treatment of Pulmonary Cunninghamella Bertholletiae Infection With Liposomal Amphotericin and Posaconazole in an Elderly Male With Psoriatic Arthritis on Immunosupression

Abstract

SESSION TITLE: Unusual Pulmonary Infections SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Cunninghamella bertholletiae is a species of zygomycetous fungi in the order Mucorales. It is a saprophytic and ubiquitous fungus found mainly in soil.It is an opportunistic fungal infection seen predominantly in immunocompromised patients,people with leukemia and uncontrolled diabetes causing extremely high mortality rate. Cunninghamella bertholletiae infections are often highly invasive, and can be difficult to treat making prompt and accurate diagnosis of this pathogen an important medical concern.Disseminated infections have also been seen in renal and hepatic transplant patients.Infection usually occurs through traumatic introductions into the body (i.e. through a wound). CASE PRESENTATION: 68 year old male patient came with complaints of high grade fever, cough and shortness of breath grade ΙΙ of 10 days duration.Patient had history of psoriatic arthritis for 3 years and was on multi-drug immunosuppression including corticosteroids,methotrexate,leflunomide.He had type 2 diabetes mellitus of 20 years duration.Lung infection was suspected and immunosuppressive therapy was stopped.Patient had hyoxia and required oxygen support, initially 5L/min later increased to 15L/min.He was put on broad spectrum antibiotics including Meropenem,Clarithromycin .CT chest showed B/L extensive subpleural and peribronchovascular ground glass attenuation with septal thickening and areas of consolidation. Bronchoscopy was performed, BAL for fungal stain showed plenty aseptate, branching broad hyphae suggestive of zygomycetes infection. Liposomal amphotericin was started in the dose of 5mg/kg/day. Patient was closely monitored in ICU over the next 10 days in view of persistent hypoxia,tachycardia,tachypnoea and worsening of chest X-ray shadows.He also received intermittent NIV support through face mask.Syrup Posaconazole was added to the regimen after 3 days of starting amphotericin as he continued to have high grade fever.Bronchial wash was negative for bacterial culture,but fungal culture grew Cunninghamella bertholletiae.After 1 week, patient was slowly weaned off from NIV support and required lesser oxygen.Antifungals were continued, he was shifted out of ICU after 14 days with minimal oxygen support.Patient showed significant clinical and radiological improvement and was closely monitored with renal and electrolyte parameters for potential complications of Amphotericin therapy. DISCUSSION: Mucormycosis is manifested by a variety of syndromes in humans, particularly in patients receiving glucocorticoids[1] and those with diabetes mellitus [2].Devastating rhino-orbital-cerebral and pulmonary infections are the most common syndromes caused by these fungi.Pulmonary mucormycosis is a rapidly progressive infection that occurs after inhalation of spores into the bronchioles and alveoli. The diagnosis of pulmonary mucormycosis is difficult since the presentation does not differ from pneumonia due to other angioinvasive molds. Chest radiographs or CT scans may demonstrate focal consolidation, masses, pleural effusions, or multiple nodules [3] but are nonspecific.Dedicated team of pulmonologists and microbiologists with aggressive search for the causative agent and prompt initiation of antifungals is required. CONCLUSIONS: Invasive fungal infections should be suspected in immunocompromised patients and aggresive search for the causative organism should be employed at the earliest.If sputum is non-representative,bronchoscopy and BAL should be done early in the course of the disease,as later on, severe hypoxia might hinder any invasive procedures,increasing the risk of respiratory failure during bronchoscopy. Multidisciplinary approach in consultation with pulmonologist, microbiologist, intensivist. nephrologist is the key in managing these patients. Lastly, due to exhausting hospital stay and economic burden due to expensive anti-fungal drugs,they are prone to anxiety/depression.An empathetic approach and day-to-day counselling of relatives played a significant role in our patient management. Reference #1: Kontoyiannis DP, Wessel VC, Bodey GP, Rolston KV. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000; 30:851. Reference #2: Kauffman CA, Malani AN. Zygomycosis: an emerging fungal infection with new options for management. Curr Infect Dis Rep 2007; 9:435. Reference #3: Chamilos G, Marom EM, Lewis RE, et al. Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer. Clin Infect Dis 2005; 41:60. DISCLOSURE: The following authors have nothing to disclose: Yashwant K O, Vijay Salla, Annapurna Mydavolu, Latha Sarma No Product/Research Disclosure Information