Chest Infections: Chest Infections I |

Mysterious Rapidly Appearing Fatal Lung Mass FREE TO VIEW

Benjamin Naberhaus, MD; Alicia Swink, MD; Joseph Guileyardo, MD; Adan Mora, MD
Author and Funding Information

Baylor University Medical Center, Dallas, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A112. doi:10.1016/j.chest.2016.02.117
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SESSION TITLE: Chest Infections I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Multiple Myeloma therapy subjects patients to a vast array of complications. We present a case of a patient with a new rapidly developing lung mass due to angioinvasive zygomycosis.

CASE PRESENTATION: A 62-year-old with IgG Lambda Myeloma s/p autologous bone marrow transplant at day 147 was admitted with diarrhea, rash, fatigue, and right arm pain. On exam, her blood pressure was 108/67 mmHg, heart rate was 94 beats/minute and she was afebrile. She had edema in her right leg and arm and a rash on her chest. She was pancytopenic and chest radiograph (CXR) showed a right lower lobe infiltrate and a pathologic arm fracture. She was admitted for fracture repair and antibiotics. On hospital day 12, she developed acute respiratory failure. CXR showed bilateral pulmonary infiltrates. Cultures were positive for stenotrophomonas. On hospital day 19, she developed worsening oxygenation and shock. Antibiotics were broadened to included Bactrim as a CXR revealed a new right upper lobe lung mass confirmed on chest computed tomography as a lobulated 5 x 5.1 cm mass. On hospital day 22, blood cultures grew Norcardia, but despite aggressive treatment and several days on bactrim, she developed worsening hemodynamic instability with organ failure. The family requested withdrawal of life sustaining therapy. An autopsy was performed. Systemic amyloidosis was present involving the heart, lungs, and multiple additional tissues. Widespread angioinvasive zygomycosis was found involving the heart, mediastinum and the hemorrhagic lung lesion.

DISCUSSION: Mucormycosis and zygomycosis are general terms for infections caused by various fungi, such as Rhizopus, Rhizomucor, Mucor and Cunnighamella. Mucormycosis is a life-threatening fungal infection that occurs primarily in patients with various immunocompromised states, such as diabetes, hematological malignancies and stem cell transplant patients and has a high mortality rate. The reported overall mortality is 80%; 65% in patients with isolated pulmonary mucormycosis and 96% in patients with disseminated disease. Pulmonary manifestations are variable and include cavitary lesions, pneumonia, solitary nodule, or disseminated lesions. The treatment usually requires a combination of surgery in resectable lesions with antifungal agents like amphotericin. Our patient was evaluated and treated since admission for infection, but not until 3 weeks into her stay did she develop a new fungal mass which was part of a widespread illness complicating her critically ill state.

CONCLUSIONS: Multiple myeloma and bone marrow transplant patients can become desperately ill and are subject to many complex and fatal complications. New radiographic findings in the chest should prompt one to think of fungal entities despite negative cultures as this requires a high index of suspicion and mortality is high.

Reference #1: Tedder M, Spratt JA, Anstadt MP, et al. Pulmonary mucormycosis: Results of medical and surgical therapy. Ann Thorac Surg 1994;57:1044-50

DISCLOSURE: The following authors have nothing to disclose: Benjamin Naberhaus, Alicia Swink, Joseph Guileyardo, Adan Mora

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