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Post Liver Transplant Patient Presenting With Poorly Controlled Diabetes, Sinusitis, and Hemoptysis: A Case of Pulmonary Mucormycosis FREE TO VIEW

William Hunt*, MD; Remzi Bag, MD
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Emory University, Atlanta, GA

Chest. 2012;142(4_MeetingAbstracts):164A. doi:10.1378/chest.1390754
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SESSION TYPE: Infectious Disease Case Report Posters I

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

INTRODUCTION: Mortality associated with mucormycosis, a rare opportunistic fungal infection, is high with reported death rates of 50-80%. Pulmonary mucormycosis can spread contiguously or disseminate hematogenously with up to 20% of patients developing disseminated disease. We present a case of pulmonary mucormycosis in a young post liver transplant patient with multiple risk factors.

CASE PRESENTATION: A 23 year-old male with history of diabetes mellitus and remote orthotopic liver transplant presented with one week of right-sided chest pain, anorexia, intermittent vomiting and productive cough with scant hemoptysis. He had run out of his insulin several days prior with ensuing uncontrolled diabetes. Review of systems was positive for sinus congestion and headache for several weeks. Physical exam was remarkable for tenderness to palpation of the frontal and maxillary sinuses with edematous nasal turbinates. He was tachycardic, but otherwise had an unremarkable chest exam. There were no focal defects on neurologic exam. Laboratory studies revealed a WBC of 27,300 per µL, serum glucose of 256 mg/dL, serum creatinine of 2.36 mg/dL, and an elevated Tacrolimus level of 26.7 ηg/mL. CT scan of the chest demonstrated a 7.7 x 7.0 cm mass-like consolidation in the right upper lobe with central cavitation. Sinus CT showed extensive opacification of all paranasal sinuses. Purulent mucus was noted descending from the right upper lobe segments on bronchoscopy. Transbronchial biopsy demonstrated pauci-septate, 90° branching fungal hyphae further characterized as mucormycosis on immunostaining.

DISCUSSION: Spread by airborne spores, mucormycosis most commonly affects the rhino-orbital-cerebral area followed by the lungs in individuals with underlying risk factors. Diabetes, particularly ketoacidosis, is the most common risk factor. Other risk factors include neutropenia, hematological malignancy, iron overload, corticosteroid use, solid organ transplantation, renal failure, injection drug use and long term voriconazole or caspofungin use. Presenting symptoms and physical findings of pulmonary mucormycosis are often times nonspecific. Hemoptysis only occurs in about 26% of the cases. Radiography is usually nonspecific as well. However, in immunocompromised individuals, the halo or reverse halo sign should prompt one to consider mucormycosis. Histopathological examination remains the current mainstay of diagnosis.

CONCLUSIONS: Mucormycosis is a rare fungal infection with recently increasing incidence paralleling growing rates of immunosuppression. Diagnosis requires a high degree of clinical suspicion as many of the typical culture techniques employed for isolation are inadequate. Treatment is aimed at correcting underlying conditions if possible and prompt initiation of antifungal therapy.

1) Roden, M.M., et al., Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis, 2005. 41(5): p. 634-53.

DISCLOSURE: The following authors have nothing to disclose: William Hunt, Remzi Bag

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Emory University, Atlanta, GA




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