Abstract Introduction Pulmonary mucormycosis is a rare, life-threatening fungal infection that can be challenging to diagnose, particularly in patients without the classic risk factors, which include diabetic ketoacidosis (DKA), immunocompromised individuals, prolonged steroids use, and iron transfusions. We present a case of pulmonary mucormycosis that required three bronchoscopies and invasive histopathological testing to establish a diagnosis. Case A 54-year-old male with a history of poorly controlled diabetes, known smoker, and recent hospitalization for severe pneumonia presented with decreased consciousness and shortness of breath. His employment was notable as a truck driver with nationwide travel exposure. On evaluation, he was found to be hypotensive and in acute hypercapnic hypoxic respiratory failure requiring emergent intubation. Labs were significant for pancytopenia, hyperglycemia (373 mg/dL) and respiratory acidosis without evidence of metabolic acidosis. A viral respiratory panel was negative. A computed tomography scan of the chest showed extensive bilateral lung infiltrates with mediastinal and hilar lymphadenopathy. He was admitted to the intensive care unit for treatment of severe sepsis due to healthcare-associated pneumonia and started on pressors and broad spectrum IV antibiotics. A bronchoscopy revealed gray-white pseudomembranes adherent to the mucosal wall. Cultures were collected and subsequently grew Stenotrophomonas Maltophilia and Achromobacter Xylosoxi. Antibiotics were adjusted, and he was eventually extubated. The hospital course was complicated by worsening dyspnea requiring reintubation. A repeat bronchoscopy showed persistent gray pseudomembranous lesions that could not be suctioned, prompting further testing as findings were inconsistent with previous resulting bacterial growth. The following day, a third bronchoscopy was performed with submucosal biopsy from beneath the pseudomembrane with Periodic acid-Schiff and Gomori methenamine silver staining for further evaluation. Rapid on-site evaluation revealed fungal elements, prompting initiation of antifungal therapy voriconazole and micafungin. Surgical pathology confirmed the pulmonary mucormycosis diagnosis on the following days and the patient was placed on definitive therapy with amphotericin B with subsequent improvement. Discussion Although this patient had uncontrolled diabetes, the absence of proven DKA or immunocompromised state initially lowered suspicion for invasive fungal disease. Retrospective review later revealed recent high-dose steroid use and DKA two weeks prior, information that was unavailable to the treating team. In these scenarios, medical decisions must be guided by presenting clinical information. Pneumonia refractory to antibiotics with bronchoscopy findings of pseudomembranes, adherent plaque, or eschar should arouse suspicion for invasive fungal infection. Bronchial lavage with staining can frequently be negative, thus histopathological testing from a biopsy remains essential for diagnosis. This abstract is funded by: Nobody
Banayan et al. (Fri,) studied this question.