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• W3134732542 abstract "Case PresentationA 51-year-old woman with a medical history of poorly controlled type 1 diabetes mellitus, hyperthyroidism, and tobacco abuse was admitted to the hospital with persistent nausea, vomiting, abdominal discomfort, dry cough, rhinorrhea, and sore throat. She denied fevers, chills, rigors, shortness of breath, hemoptysis, nasal congestion, postnasal drip, and facial pain. She denied any sick contacts, and there was no recent travel outside of Chicago. A 51-year-old woman with a medical history of poorly controlled type 1 diabetes mellitus, hyperthyroidism, and tobacco abuse was admitted to the hospital with persistent nausea, vomiting, abdominal discomfort, dry cough, rhinorrhea, and sore throat. She denied fevers, chills, rigors, shortness of breath, hemoptysis, nasal congestion, postnasal drip, and facial pain. She denied any sick contacts, and there was no recent travel outside of Chicago. Her initial body temperature was 36.8°C, but she later spiked to 38.4°C; heart rate, 140 beats/min; respiratory rate, 28 breaths/min; BP, 171/79 mm Hg; and oxygen saturation was 100% on room air. She was thin, ill appearing, lethargic, and had dry mucous membranes. Her abdomen was soft but diffusely tender with no rebound, and her chest examination was clear to auscultation bilaterally. Her heart sounds I and II were normal with no murmur, and no elevated jugular venous distention. She had no peripheral lymphadenopathy and no peripheral edema. Her skin was warm and dry but mottling. She was found to be influenza B positive in the ED, and her initial chest radiography showed no acute abnormalities (Fig 1A). Her blood gas analysis showed pH of 6.96, pCo2 of 8.8 mm Hg, and po2 of 124.4 mm Hg. CO2 level on blood chemistry was <10 mEq/L, with an anion gap of 20. Glucose level was 586 mg/dL, glycosylated hemoglobin (HbA1c) was 13%, WBC count of 16,060/μL and procalcitonin was initially 0.65 ng/mL but peaked at 8.16 ng/mL. Repeat chest radiographs obtained within 36 hours of admission showed a new left hilar consolidation, suggesting rapidly evolving pulmonary infiltrate (Fig 1B, 1C). CT of the abdomen was negative for any acute event, and a CT angiogram chest scan showed right lower lobe pulmonary embolism and a mass-like consolidation in the left lung near the hilum (Fig 2A, 2B ). Sputum cultures were positive for Acinetobacter baumannii and Stenotrophomonas maltophilia. Fungal studies including serum cryptococcal antigen, histoplasmosis urine antigen, blastomycosis urine antigen, coccidioidomycosis urine antigen, serum galactomannan assay, and 1,3-beta d-glucan serology were all negative. Fiber-optic bronchoscopy was performed, which revealed a distinct region of gray mucus extending from the left mainstem bronchus into the left lower lobe bronchus and its bifurcation to the left upper lobe. The tissue was noted to be friable and appeared necrotic (Fig 3A, 3B ). Bronchoalveolar washings cytology was negative for malignant cells, and tissue culture was negative but lung tissue pathology showed broad, wide-angle branching, nonseptate hyphae (Fig 4A, 4B ).Figure 2A, CTA of the chest with contrast that shows a large mass-like opacity in left upper lobe. B, CTA of the chest with contrast that shows a large mass-like opacity in left upper lobe devoid of vascularity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3A, Bronchoscopic image from left upper lobe showing transition point between healthy bronchial tissue and dead bronchial tissues. B, Bronchoscopic image from left lung showing a distinct region of gray mucous extending from the left mainstem bronchus into the left lower lobe bronchus and its bifurcation to the left upper lobe.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4A, Hematoxolyin & eosin stain of bronchial biopsy showing showing nonseptate, wide-angle branching hyphal forms. B, Grocott’s methenamine silver stain of bronchial biopsy showing nonseptate, irregularly branched hyphal forms.View Large Image Figure ViewerDownload Hi-res image Download (PPT) What is the diagnosis? Diagnosis: Angioinvasive pulmonary mucormycosis The terms mucormycosis and zygomycosis are used interchangeably. The most common pathogens are Rhizopus and Mucor species. Diagnosis is made by demonstrating pathogenic fungi in the tissues of a symptomatic patient. Microscopically, they are characterized by broad, nonseptate hyphae that branch irregularly at right angles and are thin walled (Fig 4A, 4B). Mucor species grow best in an acidic high-glucose medium, which explains the susceptibility of diabetic ketoacidotic patients. Infection is more common in males (65% of cases in one review), for unclear reasons. Patients may initially present with a bacterial pneumonia, because 39% of patients have concomitant bacterial or viral infection, 74% of which were bacterial pulmonary pathogens, but they rapidly progress to a life-threatening illness despite adequate antibiotics. Although spore inhalation may result in colonization, healthy individuals are not colonized because inhaled spores are eliminated by pulmonary macrophages. Pulmonary mucormycosis is characterized by angioinvasion with subsequent infarction and necrosis of affected tissues and media of large pulmonary arteries, predisposing patients to severe or fatal hemoptysis. Granulocytopenia, immunosuppression, diabetes, malignancy, bone marrow transplantation, solid organ transplantation, deferoxamine therapy, renal failure, injection drug use, and penetrating trauma are the most prevalent predisposing diseases associated with mucormycosis, but infection also has been reported in patients with no apparent immune impairment. Most patients with malignancy (60%) had pulmonary disease, whereas most patients with diabetes (66%) had sinus disease. Among patient without an identifiable predisposing condition, bilateral consolidation, pleural-based mass, upper-lobe infiltrates with cavitation, solitary pulmonary nodule, and hilar mass have all been described. Although chest films are abnormal in most patients with pulmonary mucormycosis, they are rarely suggestive of a fungal origin. The most common findings were an infiltrate and a mass, whereas pulmonary consolidation, cavitation, or an effusion were less frequently seen. Clinicians should have a high index of suspicion for pulmonary mucormycosis in patients with risk factors who develop rapidly evolving pulmonary infiltrates, especially if the patient is deteriorating despite broad-spectrum antibiotics. CT shows a “halo” sign (peri-infilterate low attenuation) or reversed halo sign and rim enhancement after the administration of contrast. The “air crescent” sign, air between a radiodense parenchymal lesion and normal tissue, is most commonly from angioinvasive fungal infections. Presence of multiple lung nodules (>10) and pleural effusion on initial CT scans was an independent predictor of pulmonary mucormycosis. Most diagnoses were established after bronchoscopy with transbronchial biopsy, although BAL, open lung biopsy, transthoracic needle aspiration, and surgical extirpation also have been effective. Outcomes are frequently devastating, with mortality of 96% in generalized disseminated disease, 85% in GI infection, and 76% in pulmonary mucormycosis. Antifungal therapy appears to improve survival, whereas surgical therapy provides additional benefit to patients with pulmonary mucormycosis confined to one lung. Roden et al reported that overall survival was 61% amongst those treated with amphotericin B deoxycholate, 57% for those treated with surgery alone, 70% for those treated with surgery and antifungal therapy, and 3% for those who did not receive any treatment for their infection. Another review reported that mortality in patients treated surgically was 11%, compared with 68% in those treated medically. Pulmonary mucormycosis is an acutely fatal infection, but early recognition combined with surgery and antifungal treatment are key to improving survival in this very devastating disease. The patient was started on oseltamivir in the ED based on her positive influenza B test. Shortly after admission, she required intubation because of severe metabolic acidosis, leading to respiratory failure. She was diagnosed with diabetic ketoacidosis and was started on diabetic ketoacidosis protocol while she was admitted to the ICU on empiric broad-spectrum antibiotics. IV heparin was used for anticoagulation. Despite appropriate antibiotic therapy, she continued to have fevers and persistent left perihilar consolidation. She was started on empiric antifungal therapy with liposomal amphotericin B immediately after bronchoscopy, and lung tissue histopathology was consistent with mucormycosis. She was transferred to a tertiary care center for cardiothoracic surgery evaluation and further treatment. Ventilation-perfusion scan showed perfusion defects throughout the entire left lung, raising concern for disseminated infiltrative mucormycosis. Video-assisted thoracoscopic surgery with debridement and decortication of the mass was performed. Pathology confirmed mucormycosis and demonstrated significant amounts of necrotic lung tissue. A left-sided pneumonectomy was performed. She completed a 6-week course of IV liposomal amphotericin and then switched to a 3-month course of isavuconazonium sulfate. She was doing well more than a year after she completed her therapy, and there was minimal impact on her activities of daily living. 1.Mucormycosis is a rare angioinvasive life-threatening infection caused by ubiquitous filamentous fungi, and the epidemiological data on this type of mycosis are scant, so it is difficult to determine the burden of disease.2.Predisposing risk factors for mucormycosis include granulocytopenia, immunosuppression, diabetes, malignancy, bone marrow transplantation, solid organ transplantation, deferoxamine therapy, renal failure, injection drug use, and penetrating trauma.3.In patients with rapidly evolving pulmonary infiltrates who are immunosuppressed or have risk factors, consider further invasive evaluation for mucormycosis.4.The drug of choice for mucormycosis is liposomal amphotericin B, and other drugs to consider include Posaconazole and isavuconazonium sulfate.5.Improved survival is seen with early diagnosis combined with surgical resection and antifungal therapy. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met." @default.
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• W3134732542 title "A 51-Year-Old Woman With a Mediastinal Mass" @default.
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• W3134732542 doi "https://doi.org/10.1016/j.chest.2020.09.261" @default.
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