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Chest Infections |

An Unusual Case of Disseminated Mucormycosis FREE TO VIEW

Sulaiman Alhassan, MD; Raghukumar Thirumala, MD
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Allegheny General Hospital, Pittsburgh, PA


Chest. 2015;148(4_MeetingAbstracts):86A. doi:10.1378/chest.2275578
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Abstract

SESSION TITLE: Chest Infections Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

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

INTRODUCTION: Mucormycosis is a fatal opportunistic fungal infection most commonly affecting organ transplant patients. It has a prevalence of 1-5 cases per 10,000 autopsies.1 We present a rare case of an immunocompetent patient with disseminated mucormycosis.

CASE PRESENTATION: Our patient is a 78-year-old male with history of COPD, was transferred to our hospital due to duodenal stricture and suspected biliary malignancy. He initially presented with obstructive jaundice requiring ERCP-stenting of a common bile duct (CBD) stricture. His clinical course was complicated by septic shock due to E. Coli and Vancomycin resistant Enterococci (VRE). Subsequently, he underwent a percutaneous cholecystostomy, which was complicated by peritoneal bile spillage. He received 4 weeks of tigecycline and fluconazole. At our hospital, his cholecystostomy tube was exchanged and biliary stent was removed. Unfortunately, he developed recurrent septic shock attributed to VRE bacteremia and Klebsiella pneumonia in spite of appropriate antibiotics including micafungin. Imaging showed pulmonary nodular ground-glass opacities and biliary ductal dilation. The patient expired after the family requested withdrawal of life support. An autopsy revealed pneumonia with angioinvasion of bronchial arteries by mucor structures, gastric ulcer with mucor and metastatic gallbladder adenocarcinoma.

DISCUSSION: Mucormycosis is caused by fungi in the genus Mucorales. These organisms are characterized by large, aseptate, branching hyphae and are angioinvasive causing tissue necrosis. The portals of entry are sino-pulmonary and cutaneous. The diagnosis of pulmonary mucormycosis is challenging since the presentation does not differ from pneumonia due to other angioinvasive fungi. Treatment is usually with amphotericin B and surgical debridement. Disseminated infection, defined as infection at ⩾2 noncontiguous sites, is identified only on autopsy specimens and is universally fatal. Despite appropriate and prolonged course of antibiotics, our patient continued to develop multiorgan failure. We suspect that the patient developed a secondary immunodeficiency due to underlying malignancy causing opportunistic infections.

CONCLUSIONS: Invasive pulmonary mucormycosis is a rapidly progressive infection. A high index of suspicion is necessary for early diagnosis and to avoid a potentially fatal outcome.

Reference #1: Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Spellberg B, Edwards J Jr, Ibrahim A. Clin Microbiol Rev. 2005 Jul;18(3):556-69.

DISCLOSURE: The following authors have nothing to disclose: Sulaiman Alhassan, Raghukumar Thirumala

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