Pulmonary Mucormycosis: Empiricism backfires

A 35-year-old male was hospitalized with hypoxemic respiratory failure and newly diagnosed acute myelogenous leukemia. After initial improvement with chemotherapy and broad spectrum antibiotics, including antifungal therapy with voriconazole, a new right upper lobe pulmonary 1.6 cm nodule was discovered during workup for persistent fever. Respiratory failure recurred and repeat CT revealed that the nodule had become a necrotic mass involving the right upper lobe, chest wall, and mediastinum, which biopsy showed to be mucormycosis. Therapy was changed to amphotericin, but the patient died. As this case demonstrates, optimal management of patients with suspected invasive fungal disease mandates a vigorous diagnostic evaluation, especially in the face of new or evolving radiographic findings. Antifungal therapies are not equal in their ability to treat non-aspergillus molds, and as such may not address the responsible pathogen. The potential downside of empiricism and diagnostic delay is demonstrated here.