Slowly progressing, and indolent pulmonary mucormycosis (zigomycosis) in a patient with an underlying multiple sclerosis, managed without immunosuppressive therapy

R. Manfredi, L. Calza, F. Chiodo

Author address: 

Bologna, IT

Abstract: 

Introduction: Mucormycosis (M) is a infrequent filamentous fungal infection borne by a very elevated fatality rate despite prompt diagnosis and adequate therapy especially in its frequent rhinocerebral presentation and/or when decompensated diabetes mellitus, neutropenia or immunosuppression are of concern. Case report: A 53-year-old female patient (p) with a multiple sclerosis previously treated with steroidsazathioprine (but controlled since 3 months without treatment), was hospitalized owing to hemophtoe in absence of other respiratory symptoms and fever. Laboratory testing did not disclose significant abnormalities (WBC, ESR and serum glucose were within limits) and tumoral markers tested negative but the detection of multiple lung infiltrates at chest X-ray and HRCT (predominant at right lobes, with an appreciable air bronchogram), prompted a bronchoscopy with biopsy-BAL involving the medial right lobar bronchus area. After an uncertain microscopy (with Aspergillus hyphae still suspected) and negative serum Aspergillus antigen search, cultures led to the isolation of Mucor spp., with tested in vitro susceptible to amphotericin B-posaconazole and resistant to itraconazole-voriconazole. Liposomal amphotericin B (3 mg/kg/day) was delivered for 6 weeks predominantly on Day-Hospital basis with favourable tolerability: no hematological, blood chemistry and urinalysis alterations occurred. One month later our p completely recovered and a repeated HRCT and bronchoscopy confirmed a complete clinical, radiological and mycological cure. Discussion: M is a rare occurrence especially when neutropenia and ketoacidosis are absent. However, anecdotal reports occurred after trauma and during COPD. Although the usual portal of entry of M is respiratory, however the rhinocerebral M remains the most frequent and life-threatening presentation. Clinicians should consider M even when obvious risk factors and an apparently slow progression are found. Diagnosis includes microscopic differentiation from Aspergilli, although mixed infections are not so rare. In pulmonary forms, percutaneous biopsy becomes sometimes needed. Liposomal amphotericin B remains the treatment of choice but surgery is sometimes necessary to debride extensive necrotic areas due to angioinvasion; some doubt remains about hperbaric O2 therapy. In our p, a slowly progressive pulmonary M was identified and cured in a reasonably short time, even in absence of underlying, active risk factors and an overwhelming clinical progression.
2006

abstract No: 

P1225

Full conference title: 

16th European Congress of Clinical Microbiology and Infectious Diseases
    • ECCMID 16th (2006)