Disseminated mucormycosis (DM) after pneumonectomy: a case report
Wang et al. BMC Infectious Diseases
Disseminated mucormycosis (DM) after pneumonectomy: a case report
Qian Wang 0 1
Bo Liu 0 1 2
Youde Yan 1
0 Equal contributors
1 Department of Infectious Diseases, The First Affiliated Hospital with Nanjing Medical University , 300 Guangzhou Road, Nanjing 210029, Jiangsu , China
2 Department of Infection Management, The First Affiliated Hospital with Nanjing Medical University , Nanjing 210029 , China
Background: Mucormycosis is a kind of rare opportunistic fungal disease and the incidence of which has gradually increased. Disseminated mucormycosis (DM) is a life-threatening infection that mostly occurs in immunocompromised patients. The lung and brain are usually involved in disseminated mucormycosis, and other sites are scare. We report the first case of disseminated mucormycosis whose infection sites included lung, skin, liver, vertebra, and spinal cord that ensued after a right lung pneumonectomy in an immunocompetent patient. Case presentation: A 20-year-old female underwent a right lung pneumonectomy for “lung cancer” presented with an intermittent fever for two years. A computed tomography (CT) scan showed an enclosed outstanding mass in the right chest wall. The patient also suffered from lower limb numbness and weakness, difficulty walking, and dysuria. Medical examination showed superficial feeling of the abdominal wall was decreased from the T7 and T8 level; muscle strength for both lower limbs was decreased; muscle tension of both lower limbs was also diminished. A biopsy through the right chest wall mass and thoracic mass by fistula of chest wall showed broad nonseptate hyphae with right-angle branching, consistent with mucormycosis. With titration of amphotericin B and its lipid complex, the patient recovered. Conclusions: Our case showed an unusual clinical presentation of disseminated mucormycosisin an immunocompetent patient.
Case report; Disseminated mucormycosis; Pneumonectomy; Immunocompetent
Mucormycosis is caused by fungi of the order Mucorales.
The most common kinds of the order Mucorales which
cause human infections include Rhizopus spp., Mucor spp.,
Lichtheimia spp., Rhizomucor spp. and Apophysomyces spp.,
especially the third members accounting for 70–80 % of all
infectious cases [
]. Mucormycosis is a life-threatening
infection that carries a high mortality rate, despite recent
advances in its diagnosis and treatment [
]. It often occurs
among immunocompromised patients, such as those with
hematological malignancies, solid organ transplantation, or
diabetes mellitus. Based on anatomic localization,
mucormycosis can be classified as rhinocerebral, pulmonary,
cutaneous, gastrointestinal, disseminated, or uncommon
Disseminated mucormycosis (DM) often involves
two or more noncontinuous organ systems with
zygomycetes in immunocompromised patients with
hematological malignancies or organ transplantation,
or in patients on deferoxamine therapy [
lung and brain are usually involved in DM, however,
other sites are scare. In this report, we describe a case
of DM in an immunocompetent young woman who
had a right lung pneumonectomy almost two year
A 20-year-old female who presented with an
intermittent fever for two years and double lower limb
numbness and weakness for one month was admitted to
hospital in January 2015. In April 2013, she underwent
a right lung pneumonectomy for “lung cancer,” while
the postoperative pathology referred to a “necrotizing
granulomatous mass.” Seven months after the operation, a
computed tomography (CT) scan showed an enclosed
outstanding mass in the right chest wall (Fig. 1).
Thereafter, the patient was hospitalized three times due to a
repeated fever and multiple bump biopsies from the
enclosed outstanding mass; however, there was no clear
diagnosis. One month before this admission, in addition
to a fever, the patient suffered from worsened lower limb
numbness and weakness, difficulty walking, and dysuria.
In the past, she was healthy and had good nutrition.
A physical examination showed an abnormal and
oncotic hard mass (10 cm × 5 cm) that protruded from
the right chest wall. A 0.3-cm-diameter external fistula
was seen in the central part of the pack (Fig. 2), which
oozed a nonodorous, yellowish turbid liquid. Coarse
sounds without moist rales or rhonchi were heard with
left lung auscultation. Superficial feeling of the
abdominal wall was decreased from the T7 and T8 level, while
a deep feeling was present. Muscle strength for both
lower limbs was decreased: 1° right and 3° left. Muscle
tension of both lower limbs was also diminished. The
bilateral Babinski sign was positive, but concavity swelling
of the lower limbs existed.
Laboratory tests showed a white blood cell count of
18.21 × 109/L, a hemoglobin level of 82 g/L, a platelet
level of 509 × 109/L, a C-reactive protein
concentration of 98.00 mg/L, an erythrocyte sedimentation rate
of 98.00 mg/L, and negative 1-3-β-D glucan and
glactomannan (GM) tests. Post right pneumonectomy, the
thoracic CT scan revealed uneven density flake soft
tissue shadows in the right chest cavity, multiple sizes
of nodules in the left lung, a soft tissue mass
(12.5 cm × 5.9 cm) around a small pneumatosis in the
right chest wall, and a reduced density in the right
liver lobe near the diaphragmatic top (January 2015,
Fig. 3). The thoracic magnetic resonance imaging
(MRI) results showed that a space-occupying lesion
existed in the right pleural and chest wall with the
T36 vertebral body and the right rib damaged, invading
the spinal channel and spinal cord (January 2015,
A biopsy through the right chest wall mass and
thoracic mass by fistula of chest wall showed broad
nonseptate hyphae with right-angle branching, consistent with
mucormycosis (Fig. 4). The mucormycosis was widely
disseminated, invading the lung, skin, liver, vertebrae,
and spinal cord.
The patient quickly developed type II respiratory failure.
A noninvasive ventilator assisted breathing, and
intravenous amphotericin B (AmB) was administered. When the
dose of AmB increased to 0.5 mg/kg/day, with the
cumulative dose reaching 150 mg, mental disorders (agitation, fear,
etc.) and cardiac arrhythmias occurred. The adverse events
disappeared when AmB was changed to liposomal AmB.
After treatment for 28 days, the patient’s body
temperature became normal and her respiratory
function as well as lower limb sensory and motor function
recovered. The size of the right chest wall mass became
smaller, and the fistula dried. Laboratory and imaging
examinations indicated that the lesions of the lung, liver,
and thoracic vertebrae were significantly smaller. The
patient was discharged back to the local hospital for
further antifungal treatment and had recovered by the
3month follow-up exam, and plastic surgery was
suggested to repair the thoracic wall.
In this report, we present a case of DM in the lung, skin,
liver, vertebrae, and spinal cord after a right lung
pneumonectomy. The lung and brain are usually involved in
]. The involvement of the vertebrae and spinal
cord in our case has rarely been reported in DM. DM
has a nonspecific manifestation, resulting in difficulties
in diagnosis [
]. In our case, it was not difficult to
speculate that it first occurred in the lung, even before the
pneumonectomy, as a necrotizing granulomatous mass
was found. Indeed, pulmonary infection is the second
most common form, accounting for more than 30 % of
]. Mucorales has a special affinity to
endothelial cells, resulting in its invasion and destruction of
small arteries. By attracting platelet adhesion and
aggregation, Mucorales can also cause thrombosis and fatal
]. This might explain the wide
dissemination of pulmonary mucormycosis in the present case.
To date, there are no known reliable clinical serological
diagnostic methods for the diagnosis of DM. Microbial
culture of secretions is time-consuming, with a low
sensitivity and a high false-positive rate. The culture of sterile
tissue may kill the pathogen because of its grinding
process (a step for preparing tissue culture samples),
which results in a low rate of positive cultures [
Therefore, the gold standard for the diagnosis of DM relies on
the characteristic mycelium and pathological changes of
the biopsy. The histopathological characteristics for
Mucorales is a wide (6–25) μm in diameter, rarely
separating hyphae and have irregular or right angle branch. The
diagnosis of pulmonary mucormycosis in this report was
based on histopathology.
DM generally occurs in severely immunocompromised
patients: it represents 1.6 % of all invasive fungal infections
and is predominant in immunosuppressed patients with
risk factors [
]. Recently, the incidence has increased
significantly, even in immunocompetent patients [
report describes DM in an immunocompetent patient. DM
is associated with a mortality rate of approximately 100 %,
but successful treatment has been reported [
Successful treatment of DM requires a rapid diagnosis, reversal
of predisposing factors, aggressive surgical excision, and
antifungal therapy [
]. AmB or its lipid complex remains
the first choice for treatment [
]. In the present case, after
titrating the dose to avoid adverse effects, the patient
Clinicians need raise awareness that DM should also be
regarded in immunocompetent individuals, especially those
with pulmonary mucormycosis. Retrospective studies
regarding the morbidity of DM in immunocompetent
individuals in the future might be necessary in order to
understand its epidemiology.
AmB, amphotericin B; CT, computed tomography; DM, disseminated
mucormycosis; GM, glactomannan; MRI, magnetic resonance imaging
This study was supported by A Project Funded by the Priority Academic
Program Development of Jiangsu Higher Education Institutions
Availability of data and materials
All the data supporting our fin dings is contained within the manuscript.
QW and BL designed the study, wrote the manuscript, participated in
literature search, and made figures and tables. YDY conceived of the study,
and participated in its design and coordination and helped to revised the
manuscript critically for important content. All authors read and approved
the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written
consent is available for review by the Editor of this journal.
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