A69-18 Invasive Tracheobronchial Mucormycosis: A Case of Extensive Endobronchial Disease

Abstract Introduction Invasive pulmonary mucormycosis predominantly manifests as angioinvasive, necrotizing disease in immunocompromised hosts. Tracheobronchial involvement is rare and can be rapidly fatal, often leading to massive hemoptysis and asphyxiation. We present a case of extensive tracheobronchial and pulmonary mucormycosis in a patient with newly-diagnosed diabetes mellitus (DM) and recent diabetic ketoacidosis (DKA). Case Description A 42-year-old male, hospitalized one month prior for DKA in the setting of newly-diagnosed DM (hemoglobin A1c 14%) complicated by acute pancreatitis, presented with ongoing dyspnea and productive cough since discharge. Computed tomography demonstrated dense consolidation involving the right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). Bronchoscopy revealed extensive mucosally-adhered, endobronchial plaques overlying posterior trachea, left upper lobe, right mainstem bronchus, and RUL bronchi with concern for full thickness involvement in RUL airways. Mild disease was noted in the left upper lobe. Endobronchial biopsy and bronchoalveolar lavage (BAL) were performed revealing Rhizopus delemar, methicillin-resistant Staphylococcus aureus (MRSA), and Candida parapsilosis. The patient was initiated on intravenous amphotericin B, posaconazole, and vancomycin. Nebulized amphotericin B was also utilized cyclically. Subsequent CT scans showed dense consolidation with cavitation in the RUL with improvement in the RML and RLL. After discussion with Thoracic Surgery, it was determined that a RUL lobectomy was not a feasible option due to extensive tracheobronchial disease. Cryoprobe ablation was attempted to debulk the endobronchial lesions and reduce burden of disease. Repeat bronchoscopies performed over the course of multiple weeks demonstrated persistent tracheobronchial disease, though there was improvement noted after cryoablation. The patient then developed massive hemoptysis. He underwent empiric right bronchial artery embolization, but he unfortunately developed recurrent massive hemoptysis and expired. Discussion This case illustrates a severe presentation of tracheobronchial and pulmonary mucormycosis. The concurrent isolation of Rhizopus species, Candida parapsilosis, and MRSA in a patient with uncontrolled diabetes highlights the vulnerability of this patient population to not only opportunistic, but polymicrobial, infection. Surgical debridement is a key part of treatment of invasive mucormycosis, but not an option in such cases with severe tracheobronchial involvement. Literature review does reveal cases where cryoablation has been successful in treatment of tracheal disease and should be considered in patients with severe tracheobronchial mucormycosis. In this case, despite aggressive, multimodal therapy, the disease progressed, highlighting the high risk of fatality of tracheobronchial mucormycosis, even with prompt diagnosis and initiation of therapy. This abstract is funded by: None