Endobronchial mucormycosis: a rare presentation of pulmonary mucormycosis diagnosed by endobronchial cryobiopsy

SESSION TITLE: Rare Pulmonary and Cardiac InfectionsSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 01:35 pm - 02:35 pmINTRODUCTION: Mucormycosis is a life-threatening opportunistic mycosis that infects a broad range of hosts with defects in innate immunity. Pulmonary mucormycosis results from the inhalation of sporangiospores or by hematogenous or lymphatic spread. Patients present with nonspecific symptoms and clinical diagnosis is often difficult. Early diagnosis is paramount for this infection. Histopathology, and positive cultures from clinical specimens are the major diagnostic modalities for mucormycosis. Treatment usually involves combination of antifungal agents and surgical resection.CASE PRESENTATION: A 40-year-old male with the history of poorly controlled type 1 diabetes mellitus (HbA1c 10.3%) presented to the emergency department with a one-week history of fever, chills, shortness of breath, and hemoptysis. On admission, the patient was febrile, tachycardic and required 3 liters of supplemental oxygen. Physical exam and laboratory workup was unrevealing. Chest X-ray was grossly unremarkable. Computed Tomography (CT) of the chest showed a cavitary mass (3.5 x 2.9 cm) in the right lower lobe. Extensive infectious workup was sent, and he was started on broad spectrum antibiotics. Despite antibiotherapy, the patient's symptoms continued to worsen. A flexible bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration was performed. Bronchoscopy revealed a yellow-colored, friable, slimy, endobronchial mass occluding the right lower lobe bronchus. Endobronchial biopsies with cryoprobe were performed. Extraction of the lesion was attempted first with cryotherapy followed by gastrointestinal biopsy forceps and lastly with polypectomy snare. However, the attempts were unsuccessful as the mass was very elastic, with the stem attached to the right lower lobe parenchyma. Histopathological examination of the specimen was consistent with pulmonary mucormycosis, with broad, non-septate hyphae, characteristic of Mucorales species. Thoracic surgery was consulted, and right middle and lower lobes lobectomy was completed. He finished a 14-day course of intravenous Amphotericin B with clinical improvement noted. He was transitioned to oral Posaconazole on discharge. At the 3 month follow up, patient reported complete resolution of symptoms.DISCUSSION: Pulmonary mucormycosis is an opportunistic angio-invasive fungal infection. Fatal hemorrhage has been described in patients with endobronchial mucormycosis after standard endobronchial forceps biopsy. The use of cryotherapy to obtain adequate biopsy specimens while minimizing the risk of bleeding should be considered whenever possible. Endobronchial mucormycosis may also be successfully treated with cryoablation.CONCLUSIONS: Physicians must have a high level of suspicion in immunocompromised patients with fever and respiratory symptoms refractory to antibiotherapy, with a low threshold for performing an invasive diagnostic procedure.Reference #1: Di Carlo P, Cabibi D, La Rocca AM, De Luca D, La Licata F, Sacco E. Post-bronchoscopy fatal endobronchial hemorrhage in a woman with bronchopulmonary mucormycosis: a case report. Journal of Medical Case Reports. 2010 Dec;4(1):1-4.Reference #2: Zuil M, Villegas F, Jareño J, Martos–Peregrin J, Llobregat N, Terreros FJ, Callol LM. Cryotherapy in the diagnosis of endobronchial mucormycosis. Journal of Bronchology & Interventional Pulmonology. 2001 Apr 1;8(2):107-9.Reference #3: Choe YH, Lee YC, Kim SR. Endobronchial Mucormycosis Successfully Treated with Flexible Bronchoscopic Cryotherapy. Am J Respir Crit Care Med. 2018;198(3):387-389. doi:10.1164/rccm.201708-1581IMDISCLOSURES: No relevant relationships by Tony AbdoNo relevant relationships by Awais BajwaNo relevant relationships by SYED HUSSAINNo relevant relationships by Houssein Youness SESSION TITLE: Rare Pulmonary and Cardiac Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Mucormycosis is a life-threatening opportunistic mycosis that infects a broad range of hosts with defects in innate immunity. Pulmonary mucormycosis results from the inhalation of sporangiospores or by hematogenous or lymphatic spread. Patients present with nonspecific symptoms and clinical diagnosis is often difficult. Early diagnosis is paramount for this infection. Histopathology, and positive cultures from clinical specimens are the major diagnostic modalities for mucormycosis. Treatment usually involves combination of antifungal agents and surgical resection. CASE PRESENTATION: A 40-year-old male with the history of poorly controlled type 1 diabetes mellitus (HbA1c 10.3%) presented to the emergency department with a one-week history of fever, chills, shortness of breath, and hemoptysis. On admission, the patient was febrile, tachycardic and required 3 liters of supplemental oxygen. Physical exam and laboratory workup was unrevealing. Chest X-ray was grossly unremarkable. Computed Tomography (CT) of the chest showed a cavitary mass (3.5 x 2.9 cm) in the right lower lobe. Extensive infectious workup was sent, and he was started on broad spectrum antibiotics. Despite antibiotherapy, the patient's symptoms continued to worsen. A flexible bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration was performed. Bronchoscopy revealed a yellow-colored, friable, slimy, endobronchial mass occluding the right lower lobe bronchus. Endobronchial biopsies with cryoprobe were performed. Extraction of the lesion was attempted first with cryotherapy followed by gastrointestinal biopsy forceps and lastly with polypectomy snare. However, the attempts were unsuccessful as the mass was very elastic, with the stem attached to the right lower lobe parenchyma. Histopathological examination of the specimen was consistent with pulmonary mucormycosis, with broad, non-septate hyphae, characteristic of Mucorales species. Thoracic surgery was consulted, and right middle and lower lobes lobectomy was completed. He finished a 14-day course of intravenous Amphotericin B with clinical improvement noted. He was transitioned to oral Posaconazole on discharge. At the 3 month follow up, patient reported complete resolution of symptoms. DISCUSSION: Pulmonary mucormycosis is an opportunistic angio-invasive fungal infection. Fatal hemorrhage has been described in patients with endobronchial mucormycosis after standard endobronchial forceps biopsy. The use of cryotherapy to obtain adequate biopsy specimens while minimizing the risk of bleeding should be considered whenever possible. Endobronchial mucormycosis may also be successfully treated with cryoablation. CONCLUSIONS: Physicians must have a high level of suspicion in immunocompromised patients with fever and respiratory symptoms refractory to antibiotherapy, with a low threshold for performing an invasive diagnostic procedure. Reference #1: Di Carlo P, Cabibi D, La Rocca AM, De Luca D, La Licata F, Sacco E. Post-bronchoscopy fatal endobronchial hemorrhage in a woman with bronchopulmonary mucormycosis: a case report. Journal of Medical Case Reports. 2010 Dec;4(1):1-4. Reference #2: Zuil M, Villegas F, Jareño J, Martos–Peregrin J, Llobregat N, Terreros FJ, Callol LM. Cryotherapy in the diagnosis of endobronchial mucormycosis. Journal of Bronchology & Interventional Pulmonology. 2001 Apr 1;8(2):107-9. Reference #3: Choe YH, Lee YC, Kim SR. Endobronchial Mucormycosis Successfully Treated with Flexible Bronchoscopic Cryotherapy. Am J Respir Crit Care Med. 2018;198(3):387-389. doi:10.1164/rccm.201708-1581IM DISCLOSURES: No relevant relationships by Tony Abdo No relevant relationships by Awais Bajwa No relevant relationships by SYED HUSSAIN No relevant relationships by Houssein Youness