Disseminated Mucormycosis in a Young Patient with Diabetic Ketoacidosis

Abstract

INTRODUCTION: Mucormycosis is a potentially fatal fungal infection that often infects patients who are immunocompromised. We present a case of pulmonary mucormycosis in a young patient admitted for a new diagnosis of diabetes in the form of diabetic ketoacidosis (DKA). CASE REPORT: A 21-year-old man with no medical history presented to the Emergency Department in February 2020, with fevers, dyspnea, cough and pleuritic chest pain. He was tachycardic, febrile and had left sided rales on lung auscultation. Labs were consistent with DKA with leukocytosis. Chest X-Ray, confirmed by computed tomography, showed a consolidative opacity in the left lower lobe. He was admitted and treated for DKA and community acquired pneumonia. He had persistent fevers and worsening consolidative opacities. Antibiotics were broadened and pulmonary and infectious disease services were consulted. Negative microbiological testing included a viral respiratory panel, blood cultures, and urine legionella antigen. Sputum culture grew 2+ mixed respiratory flora. Two sputum samples had negative acid-fast bacilli smear and tuberculosis polymerase chain reaction. HIV antibody, serum 1,3-beta-D glucan and galactomannan assays were negative. He was placed on airborne precautions and tested for SARS-CoV 2. Bronchoscopy was deferred pending this result. He developed erythema on his right flank and punch biopsy was performed on hospital day 10 which grew mold. A bronchoscopy showed markedly necrotic and devitalized endobronchial tissue (Figure). Washings and endobronchial biopsies were notable for non-septate fungal hyphae with irregular branching. The patient was started on IV liposomal amphotericin and underwent urgent left lower lobectomy. Pathology demonstrated multiple tan-white firm nodules, thrombus obstructing the main vessels and red hepatization of the entire lobe. Further staining revealed acute fungal bronchopneumonia with angioinvasion, vascular thrombi and associated parenchymal infarction. Fungal organisms morphologically consistent with Mucorales were identified. He subsequently had sharp debridement of the right flank lesion. The patient was discharged home on day 24 with intravenous amphotericin B to continue for at least 3 months. DISCUSSION: Mucormycosis should be considered in a patient with progressive pulmonary opacities despite broad spectrum antibiotic administration. Patterns of involvement include rhinocerebral, pulmonary, cutaneous, and disseminated infection. Risk factors include uncontrolled diabetes mellitus, immunosuppression, and deferoxamine therapy. No predisposing condition is identified in 18% of patients. Prophylaxis with voriconazole and echinocandins does not prevent mucormycosis infection. Beta-D glucan and galactomannan antigens are usually normal. Treatment involves antifungal drugs and aggressive resection of affected tissue.