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Pulmonary mucormycosis in a patient with uncontrolled diabetes

A 54-year-old obese woman with uncontrolled diabetes mellitus (glycemia, 644 mg/dL; glycated hemoglobin, 21.7%) presented with a 2-week history of fever and cough. The serological test results for human immunodeficiency virus infection were negative.

Chest radiography performed on admission showed nonhomogeneous consolidations in both lungs (Figure 1A). Chest computed tomography revealed multiple reversed halo signs (RHSs) in both lungs, with low attenuation areas inside the halos and thick outer rims of consolidation (Figure 1B, C ). A pulmonary biopsy revealed yeast and hyphae suggestive of mucormycosis (Figure 1D). Therefore, the patient was diagnosed with pulmonary mucormycosis. The patient had a poor prognosis and died 8 days after admission.

FIGURE 1:
(A) Chest radiograph showing rounded focal consolidations with hypertransparent centers in both lungs. Chest computed tomography images with axial (B) and coronal reconstruction with minimum intensity projection (C), demonstrating multiple reversed halo signs in both lungs, with low-attenuation areas inside the halos and thick outer rims of consolidation. (D) Grocott’s special stain identifying the presence of fungal hyphae, confirming the diagnosis of mucormycosis (×100).

Pulmonary mucormycosis, previously known as zygomycosis, is a severe, invasive lung infection caused by filamentous fungi belonging to the order Mucorales. It occurs almost exclusively in diabetic and immunocompromised patients and has a mortality rate exceeding 50%11. Agrawal R, Yeldandi A, Savas H, Parekh ND, Lombardi PJ, Hart EM. Pulmonary Mucormycosis: Risk Factors, Radiologic Findings, and Pathologic Correlation. Radiographics. 2020;40(3):656-66. Available from: https://doi.org/10.1148/rg.2020190156
https://doi.org/10.1148/rg.2020190156...
,22. Danion F, Coste A, Le Hyaric C, Melenotte C, Lamoth F, Calandra T, et al. What Is New in Pulmonary Mucormycosis? J Fungi (Basel). 2023;9(3):307. Available from: https://doi.org/10.3390/jof9030307
https://doi.org/10.3390/jof9030307...
.

The clinical signs and imaging findings of pulmonary mucormycosis are nonspecific, although the presence of RHS in patients with neutropenia is highly suggestive of the disease. Some morphological characteristics of RHS contribute to diagnostic suspicion. Reticulation inside an RHS with an outer consolidation rim > 1 cm thick, strongly suggests invasive fungal infections, particularly pulmonary mucormycosis33. Hammer MM, Madan R, Hatabu H. Pulmonary Mucormycosis: Radiologic Features at Presentation and Over Time. AJR Am J Roentgenol. 2018;210(4):742-7. Available from: https://doi.org/10.2214/AJR.17.18792
https://doi.org/10.2214/AJR.17.18792...

4. Marchiori E, Hochhegger B, Zanetti G. Importance of the reversed halo sign for diagnosis of mucormycosis. Lancet Infect Dis. 2020;20(5):538. Available from: https://doi.org/10.1016/S1473-3099(20)30266-8
https://doi.org/10.1016/S1473-3099(20)30...
-55. Marchiori E, Marom EM, Zanetti G, Hochhegger B, Irion KL, Godoy MC. Reversed Halo Sign in Invasive Fungal Infections: Criteria for Differentiation from Organizing Pneumonia. Chest 2012; 142(6):1469-73. Available from: https://doi.org/10.1378/chest.12-0114
https://doi.org/10.1378/chest.12-0114...
. Although the definitive diagnosis should be based on a biopsy, with the identification of hyphae in infected tissues, the presence of an RHS with these morphological characteristics should be sufficient for the early initiation of appropriate therapy, thereby improving the outcome.

REFERENCES

  • 1
    Agrawal R, Yeldandi A, Savas H, Parekh ND, Lombardi PJ, Hart EM. Pulmonary Mucormycosis: Risk Factors, Radiologic Findings, and Pathologic Correlation. Radiographics. 2020;40(3):656-66. Available from: https://doi.org/10.1148/rg.2020190156
    » https://doi.org/10.1148/rg.2020190156
  • 2
    Danion F, Coste A, Le Hyaric C, Melenotte C, Lamoth F, Calandra T, et al. What Is New in Pulmonary Mucormycosis? J Fungi (Basel). 2023;9(3):307. Available from: https://doi.org/10.3390/jof9030307
    » https://doi.org/10.3390/jof9030307
  • 3
    Hammer MM, Madan R, Hatabu H. Pulmonary Mucormycosis: Radiologic Features at Presentation and Over Time. AJR Am J Roentgenol. 2018;210(4):742-7. Available from: https://doi.org/10.2214/AJR.17.18792
    » https://doi.org/10.2214/AJR.17.18792
  • 4
    Marchiori E, Hochhegger B, Zanetti G. Importance of the reversed halo sign for diagnosis of mucormycosis. Lancet Infect Dis. 2020;20(5):538. Available from: https://doi.org/10.1016/S1473-3099(20)30266-8
    » https://doi.org/10.1016/S1473-3099(20)30266-8
  • 5
    Marchiori E, Marom EM, Zanetti G, Hochhegger B, Irion KL, Godoy MC. Reversed Halo Sign in Invasive Fungal Infections: Criteria for Differentiation from Organizing Pneumonia. Chest 2012; 142(6):1469-73. Available from: https://doi.org/10.1378/chest.12-0114
    » https://doi.org/10.1378/chest.12-0114
  • Financial Support: None.

Publication Dates

  • Publication in this collection
    10 June 2024
  • Date of issue
    2024

History

  • Received
    19 May 2024
  • Accepted
    27 May 2024
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