- Email: [email protected]
Pulmonary Mucormycosis in a Diabetic Patient
October 2013, Vol 144, No. 4_MeetingAbstracts Chest Infections | October 2013
Pulmonary Mucormycosis in a Diabetic Patient Said Chaaban, MD; Maha Assi, MD University of Kansas School of Medicine-Wichita, Wichita, KS Chest. 2013;144(4_MeetingAbstracts):236A. doi:10.1378/chest.1702882
Abstract SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary mucormycosis mainly occurs in patients with underlying neutropenia, undergoing induction chemotherapy, and those with graft versus host disease post hematopoietic stem cell transplant [1]. We present the case of a 43 year old female patient with poorly controlled diabetes whose workup for a non-resolving pneumonia revealed pulmonary mucormycosis. CASE PRESENTATION: We present a 43 year old female known to have severe chronic obstructive pulmonary disease (COPD), and poorly controlled type 1 diabetes mellitus with secondary nephropathy. She was evaluated in a rural hospital with 20 days history of shortness of breath, nonproductive cough and nausea but no hemoptysis or weight loss. She was found to have diabetic ketoacidosis with concomitant right upper lobe pneumonia. She received levofloxacin for 7 days with no improvement. She was transferred to a tertiary care center and was started on methylprednisolone and broad spectrum antibiotics that included vancomycin, cefepime, and metronidazole. Chest x-ray revealed a right upper lobe infiltrate and a computed tomography (CT) of the chest without contrast (fig 1) was consistent with centrilobular emphysema, a right upper lobe consolidation and a right hilar and pretracheal mass. Bronchoscopy showed significant mucosal abnormality in the right upper lobe bronchus, mainly in the anterior segment, with significant keratinization and necrosis of the mucosa concerning for squamous cell carcinoma. An endobronchial biopsy revealed mucormycosis with focal necrosis and focal abscess formation (fig 2). CT of the brain and sinuses was negative. Patient was started on liposomal amphotericin B and micafungin. She unfortunately was deemed to be a poor surgical candidate and opted for comfort care.
DISCUSSION: Mucormycosis is an aggressive infection with an in hospital mortality rate of 68% [2]. Patients with underlying malignancy have preponderance for pulmonary disease (24%) whereas diabetics have a preponderance for sinus disease (39%) [1]. Pulmonary mucormycosis is rare in diabetics, and usually presents with tracheal or endobronchial involvement [1]. Diagnosis is confirmed by microscopic examination of a tissue specimen [2]. Amphotericin B combined with surgical intervention has a better outcome than amphotericin B alone decreasing in-hospital mortality rate to 27% [2]. CONCLUSIONS: We present this case to alert physicians in general and pulmonologists in particular to consider the diagnosis of mucormycosis in the correct clinical setting. Early intervention with antifungal therapy and surgical resection tremendously affects outcome. Reference #1: Petrikkos G et.al: Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis; 54 Suppl 1: S23-34. Reference #2: Reid VJ et al.: Management of bronchovascular mucormycosis in a diabetic: a surgical success. Ann Thorac Surg 2004; 78(4): 1449-51. DISCLOSURE: The following authors have nothing to disclose: Said Chaaban, Maha Assi No Product/Research Disclosure Information
Pulmonary Mucormycosis in a Diabetic Patient Said Chaaban, MD; Maha Assi, MD University of Kansas School of Medicine-Wichita, Wichita, KS Chest. 2013;144(4_MeetingAbstracts):236A. doi:10.1378/chest.1702882
Abstract SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary mucormycosis mainly occurs in patients with underlying neutropenia, undergoing induction chemotherapy, and those with graft versus host disease post hematopoietic stem cell transplant [1]. We present the case of a 43 year old female patient with poorly controlled diabetes whose workup for a non-resolving pneumonia revealed pulmonary mucormycosis. CASE PRESENTATION: We present a 43 year old female known to have severe chronic obstructive pulmonary disease (COPD), and poorly controlled type 1 diabetes mellitus with secondary nephropathy. She was evaluated in a rural hospital with 20 days history of shortness of breath, nonproductive cough and nausea but no hemoptysis or weight loss. She was found to have diabetic ketoacidosis with concomitant right upper lobe pneumonia. She received levofloxacin for 7 days with no improvement. She was transferred to a tertiary care center and was started on methylprednisolone and broad spectrum antibiotics that included vancomycin, cefepime, and metronidazole. Chest x-ray revealed a right upper lobe infiltrate and a computed tomography (CT) of the chest without contrast (fig 1) was consistent with centrilobular emphysema, a right upper lobe consolidation and a right hilar and pretracheal mass. Bronchoscopy showed significant mucosal abnormality in the right upper lobe bronchus, mainly in the anterior segment, with significant keratinization and necrosis of the mucosa concerning for squamous cell carcinoma. An endobronchial biopsy revealed mucormycosis with focal necrosis and focal abscess formation (fig 2). CT of the brain and sinuses was negative. Patient was started on liposomal amphotericin B and micafungin. She unfortunately was deemed to be a poor surgical candidate and opted for comfort care.
DISCUSSION: Mucormycosis is an aggressive infection with an in hospital mortality rate of 68% [2]. Patients with underlying malignancy have preponderance for pulmonary disease (24%) whereas diabetics have a preponderance for sinus disease (39%) [1]. Pulmonary mucormycosis is rare in diabetics, and usually presents with tracheal or endobronchial involvement [1]. Diagnosis is confirmed by microscopic examination of a tissue specimen [2]. Amphotericin B combined with surgical intervention has a better outcome than amphotericin B alone decreasing in-hospital mortality rate to 27% [2]. CONCLUSIONS: We present this case to alert physicians in general and pulmonologists in particular to consider the diagnosis of mucormycosis in the correct clinical setting. Early intervention with antifungal therapy and surgical resection tremendously affects outcome. Reference #1: Petrikkos G et.al: Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis; 54 Suppl 1: S23-34. Reference #2: Reid VJ et al.: Management of bronchovascular mucormycosis in a diabetic: a surgical success. Ann Thorac Surg 2004; 78(4): 1449-51. DISCLOSURE: The following authors have nothing to disclose: Said Chaaban, Maha Assi No Product/Research Disclosure Information