A Case of Lung Abscesses Secondary to Mucormycosis in a Diabetic Female Patient

sinuses after inhaling fungal spores. This infection is caused by Mucorales fungi which belong to the Zygomycetes class. The incidence of Mucormycosis is approximately 1.7 cases in 1 million. They more frequently exist in rhinomaxillary area and is a rare pulmonary disease of an opportunistic fungi, which is di�cult to diagnose with an unpredictable response to treatment. They usually appear in individuals with immunocompromised states such as diabetes, long term use of corticosteroids, immunosuppressive therapy for solid organ and hematopoietic cell transplantation, and disorders like neutropenia are notably common risk factors. As a potential for relatively life-threatening condition, the disorders warrant an anticipatory approach. We report here a case of pulmonary mucormycosis in uncontrolled diabetes presented with bilateral cavitary lesions in lungs that was �rst misdiagnosed as case of Pulmonary TB, later diagnosis was made on the basis of results of bronchoscopic biopsy, and was started on amphotericin and followed up with improvement of her symptoms.

are the frequent immunocompromised states in our setup [2]. Pulmonary invasion of mucormycosis mainly results from inhalation of sporangiospores of the fungi or in some cases through hematogenous and/or lymphatic spread of the microscopic organism. Presenting complains tend to be nonspeci c like cough, chest pain, dyspnea, fever and hemoptysis [3]. It is somewhat di cult to make diagnosis when the lungs are involved particularly when no reliable serological test, PCR or skin tests exists for Mucormycosis. Culture specimen of some other organism also does not rule out the concurrent mucormycosis infection. When in doubt, the clinician has to rely on histopathological Lung Abscesses Secondary to Mucormycosis

I N T R O D U C T I O N
Mucormycosis is a rapidly advancing and hazardous form of opportunistic infection usually starts in nose and/or paranasal sinuses after inhaling fungal spores. This infection is caused by Mucorales fungi which belong to the Zygomycetes class. The incidence of Mucormycosis is approximately 1.7 cases in 1 million. They more frequently exist in rhinomaxillary area and is a rare pulmonary disease of an opportunistic fungi, which is di cult to diagnose with an unpredictable response to treatment. They usually appear in individuals with immunocompromised states such as diabetes, long term use of corticosteroids, immunosuppressive therapy for solid organ and hematopoietic cell transplantation, and disorders like neutropenia are notably common risk factors. As a potential for relatively lifethreatening condition, the disorders warrant an anticipatory approach. We report here a case of pulmonary mucormycosis in uncontrolled diabetes presented with bilateral cavitary lesions in lungs that was rst misdiagnosed as case of Pulmonary TB, later diagnosis was made on the basis of results of bronchoscopic biopsy, and was started on amphotericin and followed up with improvement of her symptoms.

A R T I C L E I N F O A B S T R A C T
specimen from affected soft tissue to make the de nite diagnosis [4].

CASE REPORT
A 60-year-old female, came to outpatient clinic with the chief complaints of productive cough and hemoptysis, signi cant weight loss for 4 months, generalized body weakness and lethargy for 1 month. Her previous medical history includes treated case of pulmonary tuberculosis on clinical grounds and uncontrolled diabetes for ve years, her average fasting sugar levels were 342mg/dl and 3month sugars control report are 13.9% HBA1C and drug history include noncompliance to oral hypoglycemic drugs and insulin. Patient was vitally stable, admitted to pulmonology ward for further proceedings. On General Physical Examination she was pale and skinny, on Chest examination there were crepitations in the right 4th to 6th ICS and left 3rd and 4th ICS. Her CBC was requested which revealed her hemoglobin to be 9.6gm/dl, platelets in range of 590/L and total WBC count of 8700 cells/dl. Biochemical investigations showed a BUN of 14.1mg/dl and creatinine 0.7mg/dl. Chest radiograph and CT chest contrast demonstrated bilateral cavitary lesions with air uid levels in left upper lobe and right middle lobe suggestive of lung abscesses ( Figure 1 and Figure 2). Sputum workup was done for microscopy and culture that came out to be negative. Bronchoscopy was performed that showed granulation tissue and grey white mucoid material seen in lateral segment of the right middle lobe blocking the airway lumen, left bronchial tree appeared to be normal with no sign of any endobronchial lesion or mucosal abnormalities, (Figure 3). Bronchoalveolar lavage analysis showed in ammatory cells and degeneration of lining though cytology came out to be negative for any evidence of malignancy. Culture was also performed on cells from lavage with negative growth after 5 days. Examination of AFB smear under light microscope, gene Xpert, AFB culture; all came out to be negative. Tissue sample were taken from lateral segment of middle lobe and sent for the pathological examination. Microscopic description showed bronchial mucosa in abundant necrotic debris containing numerous broad aseptate ribbon like fungal hyphae suggestive of Mucormycosis. Tissue culture showed no growth. After con rmation Amphotericin B 5mg/kg IV q24hr started and followed up at 6 weeks with recovery of clinical symptoms and radiologic improvement. (Figure 4 and Figure 5).

D I S C U S S I O N
The present content reports the case of a middle aged diabetic female presented with chief respirator y complaints productive cough, dyspnea and weight loss with bilateral cavitary lesions on imaging and was misdiagnosed and treated as a case of pulmonary Tuberculosis but no response to the treatment although being compliant to it, admitted for bronchoscopic diagnostic workup ,that con rmed the growth of Mucorales thus was started on amphotericin and followed up with improvement of her symptoms and radiological improvements. Mucormycosis is the name given to group of infections caused by a fungus belonging to the order of Mucorales in taxonomic classi cation. It is highly invasive and is associated with high mortality, with the most common cause (65%) being Rhizopus Non resolving Pneumonia and demonstration of cavities/abscesses on chest imaging could give a clue on further evaluation of such invasive fungal infections rather than predominant diseases like pulmonary tuberculosis in our system. To ensure better prognostic outcomes early diagnosis leading to prompt treatment that may include surgery as well as antifungal agents could result in better outcome and survival. Final diagnosis should be made on pathologic evidence of the organism's septate hyphae in damaged tissue after negative growth and culture of sputum and BAL samples. The physician should always have pulmonary Mucormycosis as his differentials in all the patients presenting with non-speci c chronic pulmonary symptoms with negative cultures and carry out above mentioned promising diagnostic methods to ensure administration of correct treatment in the rst presentation in order to promote better management for rare fungal infections in our setup.

S o u r c e o f F u n d i n g
The author received no nancial support for the research, authorship and/or publication of this article.