TRACHEAL STENOSIS MIMICKERS: A CASE OF TRACHEAL MUCORMYCOSIS

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 an invasive fungal infection most commonly seen in immunosuppressed individuals, especially those with hematologic malignancies and uncontrolled diabetes. Pulmonary mucormycosis is rare and carries high morbidity and mortality (1). We report a rare radiographic and pathologic presentation of tracheal mucormycosis in a female patient mimicking tracheal stenosis. CASE PRESENTATION: A 51-year-old woman with history of uncontrolled diabetes mellitus and hypertension presented with a month of progressive dyspnea in the setting of mediastinal lymphadenopathy and narrowing of the trachea seen on computed tomography imaging. This patient first presented to her primary care provider with one year of constitutional symptoms including weight loss, night sweats and worsening dyspnea that was initially concerning for malignancy. A computed tomography scan was obtained, and based on the findings of tracheal stenosis, she was referred for consideration of tracheal stenting. Bronchoscopy confirmed mid-tracheal narrowing with cobblestoning of the mucosa and bilateral white plaques. Pathology confirmed mucormycosis with acute inflammation and tissue invasion. She was initially treated with amphotericin but despite this, repeat bronchoscopy revealed increased distal tracheal stenosis. Micafungin was added to the regimen but there was no option for surgical intervention or stent due to inopportune location of narrowing and concern and failure of anastomosis. Since the addition of micafungin, the patient has clinically improved. Repeat bronchoscopy unfortunately continues to demonstrate ulceration and irritation, although stenosis was somewhat improved. At the time of this report, the patient is continuing with antifungal treatment. DISCUSSION: Tracheal mucormycosis remains a difficult diagnosis to make given the rarity of the disease as well as its nonspecific presentation. Our patient initially underwent workup for malignancy and only with computed tomography scan was found to have tracheal stenosis. In one review of tracheal mucormycosis cases, radiologic abnormalities appear in 94.6% of the patients, yet only 26% of the total patients received correct primary diagnosis of fungal pneumonia (2). It is important to pursue workup of concerning imaging findings, as in our patient, with bronchoscopy and biopsy in order to arrive at the correct diagnosis and initiate treatment as soon as possible. Without treatment, survival was reported to be only 3%, making early recognition of this disease entity critically important (3). CONCLUSIONS: Tracheal mucormycosis is a rare condition, yet deadly, if untreated. In immunocompromised patients with nonspecific findings and radiographic evidence of bronchopulmonary invasion, including tracheal stenosis, mucormycosis should remain on the differential and be evaluated using bronchoscopy and biopsy for histologic confirmation of pulmonary fungal invasion. Reference #1: Spellberg B, Edwards J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clin Microbiol Rev. 2005;18(3):556–559. Reference #2: He, Ruoxi, et al. “Report of 12 Cases with Tracheobronchial Mucormycosis and a Review.” The Clinical Respiratory Journal, vol. 12, no. 4, 2018, pp. 1651–1660., doi:10.1111/crj.12724. Reference #3: Rüping MJ, Heinz WJ, Kindo AJ, et al. Forty-one recent cases of invasive zygomycosis from a global clinical registry. J Antimicrob Chemother. 2010;65(2):296–302. DISCLOSURES: No relevant relationships by Amy Bellinghausen, source=Web Response Owner/Founder relationship with Restore3D Please note: $1-$1000 by George Cheng, source=Web Response, value=Ownership interest Consultant relationship with Medtronic Please note: $1001 - $5000 by George Cheng, source=Web Response, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 by George Cheng, source=Web Response, value=Consulting fee Consultant relationship with Intuitive Surgical Please note: $20001 - $100000 by George Cheng, source=Web Response, value=Grant/Research Support Consultant relationship with Pinnacle Biologics Please note: $1-$1000 by George Cheng, source=Web Response, value=Consulting fee No relevant relationships by Erica Lin, source=Web Response No relevant relationships by Russell Miller, source=Web Response No relevant relationships by Matthew Nobari, source=Web Response No relevant relationships by Alexandra Sykes, source=Web Response