Chronic pulmonary mucormycosis: an emerging fungal infection in diabetes mellitus

Abstract

A 60-year-old diabetic female presented with fever and productive cough with hemoptysis for two months. There was no significant past medical or surgical history. Crackles were audible at right middle and lower part of chest. Rest of the physical examination was unremarkable.On laboratory investigations, total leucocyte count (TLC) was 13.1×10 9 /L with 73.6% neutrophil, potassium (K) was 5.5 mg/dL, creatinine was 1.1 mg/dL. Glycated hemoglobin (HbA1c) was 13.1%. Serial chest X-rays showed persistent homogenous consolidation in right lower lung ( Figure 1A). So computed tomographic (CT) scan chest was done which showed a consolidation with cavitary lesion in right middle lobe ( Figure 1B). Fibreoptic bronchoscopy revealed anthracosis of right middle lobe, biopsy and bronchoalveolar lavage (BAL) was taken. BAL was negative for acid fast bacilli (AFB), fungal smear showed numerous aseptate hyphae which later failed to grow. Histopathology revealed large collections of aseptate hyphae infiltrating the lung parenchyma, periodic acidSchiff and Gomori methenamine silver stains were positive suggestive of pulmonary Mucor (Figure 2A,B). She was started on amphotericin B deoxycholate 1.5 mg/kg/dose and underwent right middle lobectomy. Patient remained well and discharged home on amphotericin. She received a total cumulative dose of 3 grams of amphotericin B deoxycholate. Her medications were adjusted to achieve good glycaemic control and showed significant improvement on clinic follow ups. Case 2A 60-year-old diabetic female presented with history of cough and fever for one month. She had taken multiple antibiotics without any improvement. Crackles were audible in left middle to lower part of chest. Complete blood count (CBC) showed TLC of 11.8×10 9 /L with 68.8% neutrophils.Random blood sugar was 284 mg/dL and HbA1c was 11.4%. Chest X-ray showed left hilar soft tissue mass with perihilar infiltrates (Figure 3A). High-resolution CT chest for mucormycosis, with rhino-orbital-cerebral involvement as a common presentation. Pulmonary mucormycosis (PM) although a rare presentation in diabetic patients but is associated with high mortality and morbidity. An early diagnosis of PM is difficult, due to rarity of the disease and clinical and radiological features resembling tuberculosis (TB) which is common in Pakistan. Here we present three cases of chronic PM in patients with diabetes and with no other apparent risk factors.

Pulmonary Mucormycosis: A Case Report of a Rare Infection with Potential Diagnostic Problems

“…Recent reclassification has abolished the class zygomycetes, and hence, the term zygomycosis is inappropriate for use, although it may still be used to address mucormycosis [1]. Pulmonary mucormycosis is a devastating and life-threatening infection if not correctly diagnosed and treated [9]. The mononuclear and polymorphonuclear phagocytes of normal hosts kill Mucorales by generation of oxidative metabolites and the cationic defensins.…”

Mucormycosis prevalence in diabetic individuals in the northeast of Iran: a 10-year retrospective study

“…It seems that in diabetic individuals with mucormycosis, early diagnosis, early surgery and necrotic tissue removal, appropriate antifungal therapy, and control of risk factors such as diabetes are the main parameters for successful management of this infectious disease [19]. It appears that the mortality rate of individuals with pulmonary mucormycosis is about 76% [20], while researchers in a study found that a lower mortality rate occur in individuals with only bronchial involvement due to the limited extent of the disease to the bronchial area [21].…”

“…Diagnosis of this disease is difficult because these fungi are not properly stained by routine laboratory stains and does not grow easily in the culture medium. The reliable diagnostic method for this fungus is microscopic examination [20]. The average time for diagnosis from the onset of the disease is about 16.2 days [22].…”

The Lung Mass and nodule: a case series

“…"Halo sign", "reversed halo sign" may be correlated with massive hemoptysis [14]. Diabetic patients are more at a risk of developing the endo-bronchial disease [15]. Our patient presented with sign and symptoms that mimic tuberculosis, so he was diagnosed as a case of TB outside and was started with anti-tubercular drugs.…”