Abstract
We present a case of disseminated Mucormycosis following lung transplantation.
A 74-year-old man presented with subacute worsening body aches, left chest discomfort, bilateral ankle, knee, hand, and finger pain after a trip back from Grand Junction, Colorado to Phoenix, Arizona. He had a painful enlarging lesion on his left calf. He had diabetes and chronic kidney disease. He underwent bilateral lung transplant for pulmonary fibrosis 864 days ago. He required salvage therapy for de-novo donor specific antibodies one-year post-transplant. He was last well five weeks ago. He was on standard triple immunosuppression, trimethoprim-sulfamethoxazole, acyclovir, and posaconazole. In the ED, he was afebrile, with heart rate 93/min, breathing 18-20/min, BP 208/125 mm Hg, O2 96%. He had crackles in left upper lung zone; left calf had a tender nodule with central ulceration and ring ecchymosis (fig 1). Labs showed 46% bands, sodium 123 mmol/l, bicarbonate 13 mmol/l, blood urea nitrogen 41 mg/dl, creatinine of 1.66 mg/l, glucose 483 mg/dl. A chest radiograph (fig2) and computed tomography showed large left upper lobe consolidation (fig 3). Bronchoscopy and transbronchial biopsy showed invasive fungal hyphae resembling Mucor. He was started on intravenous isavuconazonium, inhaled and intravenous amphotericin, and empiric antibiotics. MMF was held, and tacrolimus goal trough lowered. He underwent left upper lobectomy on day 3; cultures from his lung and leg grew Rhizopus. Amphotericin was stopped due to nephrotoxicity. An MRI done for neuro changes showed multiple infarcts, T2 FLAIR hyperintensities with mass effect in right basal ganglia and internal capsule (fig 4). He succumbed to multiorgan failure on day 14.
Mucormycetes are aggressive pathogens that show no respect for tissue boundaries. Our case demonstrates the futility of even a multipronged approach if disseminated/multiorgan disease is seen at presentation.