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Chest Infections |

A Rare Case of Disseminated Mucormycosis in a Diabetic Patient Without Severe Immunocompromise

Arta Lahiji*, MD; Wilson Quezada, MD
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UCLA Olive View Medical Center, Sylmar, CA


Chest. 2012;142(4_MeetingAbstracts):246A. doi:10.1378/chest.1390418
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Abstract

SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Mucormycosis is a rare fungal infection that typically occurs with an underlying condition including diabetes mellitus (DM), malignancy, organ transplantation, deferoxamine therapy, injection drug use, bone marrow transplantation, and renal failure. Common primary infection sites include sinus, pulmonary, cutaneous, cerebral, gastrointestinal, and renal. Patients with DM typically present with rhinocerebral, pulmonary, and sino-orbital disease. Disseminated disease (defined as infection at > 2 non-contiguous sites) has been reported in 23% of cases, typically occurs in patients with severe immunocompromise, and is associated with a mortality of 96%. Treatment involves a combination of antifungal therapy, surgical debridement and/or lobectomy with single lobe pulmonary involvement.

CASE PRESENTATION: This is a 68 year-old female with a past medical history of uncontrolled DMII, end stage renal disease on dialysis, and congestive heart failure (CHF), with recent history of C. difficile , admitted with acute on chronic CHF in the setting of missed dialysis. She developed worsening shortness of breath and a chest CT on hospital day (HD) #10 showed a large RLL cavitating pneumonia and she was started on empiric broad spectrum antibiotics. A pigtail catheter and subsequently a larger chest tube was placed on HD #11. Pleural fluid cultures grew H. influenzae , C. albicans and Rhizomucor sp , and amphotericin B and posaconazole were started on HD #16. The patient was not a good surgical candidate and despite aggressive antifungal therapy, suffered two PEA arrests after an episode of severe hemoptysis. Resuscitation was unsuccessful and the patient died HD #20. Post mortem examination revealed disseminated mucormycosis involving the lung, pancreas, thyroid, and spleen.

DISCUSSION: While mucormycosis may occur in patients with no immune impairment, or greater immunocompetency, such as in DM alone, disseminated mucormycosis typically occurs in patients with severe immunocompromise. In a series of 929 patients, the risk factors that were shown to be associated with disseminated mucormycosis include burns, prematurity, and deferoxamine use, while DM was not shown to be a risk factor, and was actually associated with a decreased odds of disseminated disease (OR=0.29, 95% CI 0.17-0.51). Disseminated mucormycosis as seen in our patient with underlying DM and renal failure without severe immunocompromise is uncommon but nevertheless was fatal despite aggressive antifungal therapy. While treatment typically significantly improves survival, mortality remains high particularly in disseminated disease, as evident even in our patient without severe immunocompromise.

CONCLUSIONS: Although rare, disseminated mucormycosis should be considered and aggressively managed even in patients without severe immunocompromise.

1) Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005; 41:634.

DISCLOSURE: The following authors have nothing to disclose: Arta Lahiji, Wilson Quezada

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UCLA Olive View Medical Center, Sylmar, CA

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