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Disorders of the Pleura |

Atypical Presentation of Rhizopus Pneumonia in a Multivisceral Transplant Patient

Nina Kolbe, DO; Keith Killu, MD; Lisa Louwers, MD; Stephanie Bakey, DO; Dionne Blyden, MD; Victor Coba, MD; Mathilda Horst, MD
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Henry Ford Hospital, Detroit, MI


Chest. 2014;146(4_MeetingAbstracts):462A. doi:10.1378/chest.1988822
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Abstract

SESSION TITLE: Miscellaneous Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Mucormycosis is a rare opportunistic fungal infection. Rhizopus spp is the most common class of Mucorales to cause infection in the immunocompromised population. Pulmonary mucormycosis commonly presents with angioinvasion and pulmonary infarction with cavitary lesions, at times requiring surgical resection.

CASE PRESENTATION: A 53 year old female was admitted to the surgical intensive care unit after undergoing a multivisceral transplant including stomach, pancreas, liver, and small intestine. She previously underwent a failed small bowel transplant one year prior requiring lifelong total parenteral nutrition, complicated by Candida albicans fungemia. Her protracted hospital course included chronic respiratory failure, requiring mechanical ventilatory support. Imaging studies revealed bilateral ground glass opacities consistent with multifocal pneumonia and large bilateral loculated pleural effusions. Multiple bronchial alveolar lavage (BAL) specimens demonstrated Rhizopus spp. Liposomal Amphotericin B and Posaconazole were started, and her immunosuppression was minimized. Liposomal Amphotericin B was eventually discontinued due to nephrotoxicity. Additional investigation lead to the isolation of an intra-abdominal abscess with Candida albicans and pleural effusions with Pseumdomonas putida and vancomycin-resistant enterococcus. The antibiotics were adjusted to daptomycin, meropenem and colistin. Further BAL cultures did not demonstrate Rhizopus and imaging studies showed a resolution of pneumonia. She continued on Posaconazole for a 6 month duration.

DISCUSSION: The primary site of mucormycosis infection varies dependent on host factors. Solid organ transplant patients have a threefold risk of developing pulmonary mucormycosis. An atypical presentation of pulmonary mucormycosis includes a less fulminant chronic respiratory infection with prolonged constitutional symptoms. Early isolation and diagnosis is crucial to prevent dissemination. In transplant patients, minimizing immunosuppression is beneficial. Recommendations for antifungal treatment include Liposomal Amphotericin B and Posaconazole until cultures are negative, radiographic improvement, and recovery from immunosuppression.

CONCLUSIONS: This case demonstrates how a high index of suspicion for rare fungal infections with an atypical presentation led to a prompt diagnosis of Rhizopus pneumonia. Early treatment and adjustment of immunosuppression medications led to a favorable outcome in a post multivisceral transplant immunocompromised host.

Reference #1: Kontoyiannis D, Lewis R. Invasive Zygomycosis: Update on Pathogenesis, Clinical Manifestations, and Management. Infect Dis Clin N Am 2006;60:581-607.

Reference #2: Roden M, Zaoutis T, Buchanan W, et al. Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases. Clin Inf Dis 2005;41:634-53.

Reference #3: Spellberg B, Edwards J, Ibrahim A. Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management. Clin Microb 2005;556-569.

DISCLOSURE: The following authors have nothing to disclose: Nina Kolbe, Keith Killu, Lisa Louwers, Stephanie Bakey, Dionne Blyden, Victor Coba, Mathilda Horst

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