Pulmonary Mucormycosis presenting as a lung mass in Renal Transplant patient– A Case Report
Michael Prochaska, MD, Shefali S. Ballal, MD, Yulan Gong, MD, Beth Mapow, DO
Department of Pathology, Drexel University College of Medicine, Philadelphia, PA, USA
Background
Discussion, con’t
Mucormycosis is a highly invasive fungal infection
caused by fungi in the recently proposed subphylum
mucoromycotina and order mucorales 1. It most
commonly affects immunocompromised hosts,
particularly those with hematologic malignancies and
solid transplant recipients2. The mortality has been
reported to range between 50% and 80% in cases of
localized disease and as high as 98% for disseminated
disease 3.
Case Presentation
We present a 64 year old man who was admitted in
January 2015 for progressive shortness of breath and
exercise intolerance over a course of 3 months. His
past medical history is significant for coronary artery
disease and diabetes mellitus. The patient had
undergone a renal transplant in February 2013 for end
stage renal disease secondary to diabetes mellitus
with subsequent episodes of rejection.
Chest radiography on admission demonstrated a right
upper lobe lung lesion. A subsequent CT chest scan
without contrast showed a new gas containing
spiculated mass in right upper lobe measuring 2.3 x
3.0 x 2.7 cm. The patient underwent CT guided
biopsy of the lesion. Initial adequacy assessment
revealed fungal elements and necrosis. The fungal
elements were confirmed to be morphologically
consistent with mucorales species on histology
(Figs1,2). The patient was started on amphotericin B
and aggressive surgical debridement and resection of
the cavitary lung lesion was recommended. The
patient underwent a right upper lobectomy in February
2015. Histology showed lung parenchyma with
necrotizing granulomas and angioinvasive fungal
organisms morphologically consistent with mucorales
species (Figs 3,4). In spite of adequate medical
therapy, the patient became clinically unstable and
expired shortly thereafter.
Discussion
Mucor was first described by Paltauf in 1885 4.
They are broad, non septated hyphae with right
angle branching with predilection for blood
vessels causing thrombosis and ischemia 5.
Invasive fungal infection including mucormycosis
following renal transplant occur in 1-2% of
patients in developed countries. The disease
manifests at a median of six months posttransplant and is associated with high dosage
immunosuppressive therapy6.
Figure 1: H&E showing broad non
septated mucorales hyphae
Figure 2: GMS stain highlighting
mucorales hyphae
Pulmonary mucormycosis findings on CT scan include
lung nodules, cavitation with pleural effusion, and
bronchopneumonia7. However the radiographic signs of
pulmonary mucormycosis are nonspecific and can be
difficult to distinguish from other infections. Hence tissue
biopsy is the gold standard for obtaining a diagnosis of
pulmonary mucormycosis8.
Pulmonary mucormycosis occurs after inhalation of fungal
sporangiospores which may spread locally or disseminate
systemically. Angioinvasive infections often result in
infarction of the affected tissue. Invasion of the large
mediastinal vessels can lead to massive hemoptysis
which could occasionally be fatal9.
The predisposing factors for mucormycosis include
ketoacidosis, uncontrolled diabetes mellitus, renal failure,
solid tumors, immunosuppressive therapy and solid organ
transplantation10. Our patient had multiple risk factors
including diabetes mellitus, renal transplant and
immunosuppressive therapy.
A combination of surgical excision and anti-fungal therapy
has been shown to be optimal treatment for mucormycosis
along with correction of the underlying condition2,7.
Despite aggressive treatment, invasive mucormycosis
carries a high mortality rate with the overall mortality for
pulmonary mucormycosis being 76%3.
Conclusion
Figure 3: Section of the lung showing
a necrotic brown mass
Figure 4: H&E showing fungal
hyphae invading the bronchus
It is important that clinicians maintain a high degree of
suspicion for pulmonary mucormycosis in case of
immunocompromised patients. In our case, high clinical
suspicion and early radiographic intervention along with
tissue diagnosis were crucial in identifying
mucormycosis. The patient was actively treated with
antifungal and surgical therapy. However the patient’s
comorbid conditions contributed to his demise.
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