SESSION TITLE: Infectious Disease Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: We present a case of an unusual presentation of disseminated mucormycosis presenting with right ventricular failure, pulmonary infiltrate, and initial pancytopenia in a patient with no known medical problems.
CASE PRESENTATION: We report a case of a 44 year old previously healthy male who presented with hemoptysis and hypoxemic respiratory failure in the setting of a right lower lobe infiltrate on CT with no evidence of pulmonary embolism. He was transferred to our tertiary care ICU intubated and required multiple vasopressors. Initial laboratory studies showed pancytopenia with a WBC count of 2800 with a left shift; over his course this increased to a peak of 79,000 with a left shift. BAL was minimally bloody with negative cultures. Echocardiogram showed right ventricular dysfunction including McConnell’s and 60/60 signs. The patient did not improve despite broad spectrum antibiotics and stress dose corticosteroids. On day 7 the patient developed a necrotic eschar that was biopsied and showed intravascular hyphae consistent with Rhizopus (Fig 1). Repeat CT showed multifocal necrotizing pneumonia and wedge shaped infarcts in the spleen and right kidney. Despite starting on amphotericin, the patient’s status remained unchanged and care was withdrawn on day 11. On autopsy, the patient had disseminated Rhizopus with heavy involvement of the lung, including necrosis and thromboembolism. Bone marrow evaluation revealed myelodysplastic syndrome.
DISCUSSION: The pulmonary and disseminated forms of Mucormycosis are pertinent to the critical care physician because of their high mortality rate, and frequently, variable nonspecific presentations as is demonstrated by our case. Radiologic presentation of pulmonary mucormycosis is often nonspecific and often varies with the patient’s degree of immunosuppression (1). CT findings of halo sign, reverse halo sign and air crescent are more suggestive of invasive fungal pneumonia but are either insensitive, transient or unable to differentiate pulmonary mucormycosis from other invasive fungal infections (2). BAL cultures are known to be insensitive for mucormycosis (3). In this case the diagnosis was delayed as no finding was specific for the diagnosis until the appearance of the skin lesion at day 7 and subsequent biopsy.
CONCLUSIONS: As mucormycosis has a propensity for vascular invasion and subsequent thrombosis, signs and symptoms of respiratory compromise, pulmonary infiltrates, and right heart failure should raise the possibility of mucormycosis in the appropriate setting.
Reference #1: Walsh TJ et al. Early clinical and laboratory diagnosis of invasive pulmonary, extrapulmonary, and disseminated mucormycosis. Clin Infect Dis. 2012; 54(Suppl 1)S55-60
Reference #2: Marom EM, Kontoyiannis DP. Imaging studies for diagnosing invasive fungal pneumonia immunocompromised patients. Curr Opin Infect DIs. 2011;24(4):309-14
Reference #3: Kontoyiannis DP et al. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis. 2000;30(6):851-56
DISCLOSURE: The following authors have nothing to disclose: Arhaanth Reddy, Alexander Huang, Disha Mahendra, David Chen, Louis Dehner, Praveen Chenna
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