Atypical Presentation of Pulmonary Mucormycosis

Abstract

INTRODUCTION: Pulmonary mucormycosis is a rare opportunistic infection with life-threatening complication in immunocompromised patients (1). Predilection for mucormycosis is difficult given its varied presentation. We report an atypical presentation of underlying pulmonary mucormycosis. CASE PRESENTATION: A 45-year-old female with a history of an expanded criteria donor transplant with basiliximab induction five month prior to presentation with recent grade 2a rejection with intravenous steroid treatment, human immunodeficiency virus on HAART, history of deep vein thrombosis, pulmonary hypertension and diastolic heart dysfunction presented for exertional dyspnea, bilateral lower extremity edema, three-pillow orthopnea and marked decrease exercise tolerance without fever, chills or cough for two days. On exam findings showed elevated blood pressure, clear lungs and bilateral lower extremities pitting edema. The patient was presumed to be in heart failure with a BNP of 1857, however chest radiograph showed a left upper lobe consolidation. She underwent a computed tomography (CT) scan of the chest which demonstrated a 4.7 cm thick walled cavitary mass in the left upper lobe with surrounding ground glass opacities. At this time the patient remained stable and was started empirically on piperacillin/tazobactam and posaconazole. She underwent a transbronchial biopsy of the mass, which was found to be mucormycosis. Her hospitalization was subsequently complicated by hypoxic respiratory failure, renal failure requiring hemodialysis, thrombocytopenia and right hemiparesis. CT scan of the brain demonstrated multiple low attenuation lesions throughout the parenchyma suggestive of multifocal abscesses with extensive mass effect and herniation. Brain flow scan findings were consistent with brain death. Patient care was terminated on day fifteen of hospitalization. DISCUSSION: Mucormycosis is a rare, aggressive, life-threatening angioinvasive fungal infection that usually occurs in immunocompromised patients. On chest imaging, pulmonary mucormycosis may present with focal consolidation, lung masses, pleural effusions, or multiple nodules, however direct histological examination of the tissue biopsy remains the gold standard for diagnosis (2). CONCLUSIONS: Despite our patient's extensive risks for mucormycosis given her HIV and recent renal transplant status, her clinical presentation was not typical for pulmonary mucormycosis however her radiographic findings suggested otherwise. Thus it is important for clinicians to maintain a high degree of suspicion for mucormycosis in immunocompromised patients.