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Critical Care |

A "Brush" With Death: Opportunistic Infection in an Immunocompetent Host

Himaja Koneru, MD
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William Beaumont Hospital, Royal Oak, MI


Chest. 2015;148(4_MeetingAbstracts):273A. doi:10.1378/chest.2268995
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Abstract

SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Mucormycosis is any fungal infection caused by fungi that belong to species Mucorales.Routes of infection include inhalation, inoculation and ingestion.Direct inoculation from skin represents 10-20% of all reported cases.Infection is usually associated with risk factors such as uncontrolled diabetes, malignancy, HIV infection and with certain treatments like immunosuppressant therapy and iron chelation with deferoxamine.

CASE PRESENTATION: A healthy 48 year old female with no past medical history presented for fever, progressive dyspnea, and a healing rash that developed after she brushed against a tree six weeks prior.In the week prior to presentation,she was treated for pneumonia and plant dermatitis with amoxicillin-clavulanate and prednisone.Her dyspnea gradually worsened.Imaging showed left lower lobar pneumonia. Blood cultures were negative and sputum gram stain showed few polymorphonuclear leucocytes with negative final cultures.Despite 10 days of empiric IV levofloxacin, she developed hypoxemic respiratory failure requiring intubation.Meropenem and vancomycin were started. Bronchoscopy with lavage fluid sent for bacterial,viral and fungal cultures showed no growth and no cytological abnormalities.Evaluation for HIV,hepatitis,diabetes,rheumatologic and hematologic involvement was noncontributory.Multisystem organ failure rapidly ensued and she was placed on Extra Corporeal Membranous Oxygenation (ECMO) on day 14 of hospitalization.Amphotericin B was empirically initiated. Despite aggressive medical care, the patient expired 20 days after presentation.Tissue samples at autopsy revealed angioinvasive pulmonary mucormycosis with diffuse alveolar hemorrhage.

DISCUSSION: Fungi causing mucormycosis are often aggressive and ubiquitous.Once the skin barrier is breached, these fungi can invade underlying tissues growing and the intravascular and perivascular spaces exhibiting lymphangitic spread causing hemorrhage and thrombosis.Diagnosis is by histopathology which shows thick-walled hyphae branching at right angles.Dissemination is often fatal and is associated with approximately 90% mortality.Treatment options include amphotericin B and surgical resection.

CONCLUSIONS: The diagnosis of mucormycosis is extremely challenging and high degree of suspicion is required.Symptoms can often mimic a rheumatological process, the treatment of which is immunosupression that could potentiate underlying infection.Invasive diagnostic modalities for tissue diagnosis should be employed in cases where there is a rapid clinical decline.This would lead to early intervention thereby reducing mortality.

Reference #1: Sarrami AH, et al. “Fatal disseminated mucormycosis in an immunecompetent patient: a case report and literature review.” International Journal of Preventative Medicine. (2013) Dec; 4(12):1468-71.

Reference #2: Arnaiz-Garcia ME, et al. “Cutaneous mucormycosis:Report of five cases and review of the literature.”Journal of Plastic, Reconstructive & Aesthetic Surgery .(2009) 62, 434-441.

DISCLOSURE: The following authors have nothing to disclose: Himaja Koneru

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