UNEXPECTED DIAGNOSIS IN A 49-YEAR-OLD FEMALE WITH HEMOPTYSIS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hemoptysis is a common but potentially life-threatening symptom requiring urgent evaluation. The most common causes include respiratory tract infections and malignancy. We present a case of an uncommon infectious etiology of hemoptysis in an immunocompetent female. CASE PRESENTATION: A 49-year-old female presented with cough and hemoptysis. She is a never smoker, lives in Southern New Jersey, and keeps dogs, chickens and goats. She had no significant travel history. Chest CTA demonstrated an irregular 2.5 cm right lower lobe nodule. Biopsy of the lung nodule revealed peribronchial and alveolar tissue with necrotizing granulomatous inflammation. No definitive fungi or mycobacteria were identified on tissue staining. An infection could not be ruled out due to the low sensitivity of the tests. Tissue culture was not initially completed due to high suspicion for malignancy. She had persistent hemoptysis mainly with exertion. Bronchoscopy was performed with bronchoalveolar lavage revealing a friable and edematous mucosa with purulent secretions in the right lower lobe. Bronchial washing sample demonstrated black fragmented tissue. Fungal culture revealed Rhizopus species. She was placed on posaconazole and at follow-up has had an improvement in overall symptoms, although she still endorses fatigue. DISCUSSION: Mucormycosis is an opportunistic fungal infection with a high mortality rate caused by environmental molds, often Rhizopus species. It has an incidence of 3.0 cases per million populations in the U.S. There has been a rise in its incidence globally, perhaps due to an increase in susceptible populations. Risk factors include diabetes mellitus, malignancies (hematological and solid organ tumor), transplant recipients (hematopoietic stem cell and solid organ transplants), corticosteroid therapy, and neutropenia. Our index patient had none of these risk factors except for repeated environmental exposure to animal waste and thus persistent inhalation of fungal spores. Clinical forms of the infection include rhino-cerebral, cutaneous, pulmonary, and disseminated disease. Diagnosis is made through a histopathological finding of characteristic hyphae with tissue necrosis and angioinvasion or culture of a specimen from the infection site. Recommended therapy includes a combination of surgical intervention and antifungal treatment with amphotericin B. Posaconazole is an alternative antifungal with a better safety profile used most often as a step-down or salvage therapy from amphotericin B. CONCLUSIONS: Pulmonary mucormycosis has high morbidity and mortality. It is important to keep broad differential diagnoses and obtain a thorough history during the initial evaluation of hemoptysis. REFERENCE #1: Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int. 2017;114(21):371-381. REFERENCE #2: Prakash H, Chakrabarti A. Global Epidemiology of Mucormycosis. J Fungi (Basel). 2019;5(1):26. Published 2019 Mar 21. doi:10.3390/jof5010026 REFERENCE #3: Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh T, Kontoyiannis D. Epidemiology and Clinical Manifestations of Mucormycosis, Clinical Infectious Diseases, 2012. 54(1): S23–S34 DISCLOSURES: No relevant relationships by Kaitlyn Dalsey, source=Web Response No relevant relationships by Lisa Ezegbu, source=Web Response no disclosure on file for Frances Loftus; no disclosure on file for Manish Trivedi