Sudden death by pulmonary emboli from disseminated mucormycosis in a transplant patient on voriconazole prophylaxis.

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Sudden death by pulmonary emboli from disseminated mucormycosis in a transplant patient on voriconazole prophylaxis.

Chest. 2014 Mar 1;145(3 Suppl):621A

Authors: Sta Cruz JP, Tuazon S, Non L

Abstract
SESSION TITLE: Transplantation Case Report PosterSESSION TYPE: Case Report PosterPRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PMPURPOSE: To present a case of a bone marrow transplant patient who presented initially with pulmonary infiltrates who developed disseminated mucormycosis while on voriconazole prophylaxis.
METHODS: Review of records and literature.
RESULTS: A 68 year-old woman with refractory acute myelogenous leukemia on voriconazole prophylaxis was previously admitted for neutropenic fever and multifocal pneumonia suggestive of a fungal etiology on chest computed tomography (CT). She was discharged improved on antibiotics and treatment dose voriconazole for presumed invasive aspergillosis. No bronchoscopy was done. One month later, she was admitted for fever and dyspnea with a new left lower lobe consolidation on chest CT. Levofloxacin was prescribed and voriconazole was continued. After three weeks, the patient clinically improved and was cleared for bone marrow transplantation. Her pre-transplant chest CT showed slight improvement of her left lower lobe infiltrate. Three days post-transplant, however, patient complained of right hand tremor and weakness, and new left pleuritic chest pain followed by sudden onset of respiratory distress and hypoxia requiring intubation. Chest x-ray showed worsening bilateral infiltrates. An hour after intubation, the patient arrested and expired. Autopsy revealed Rhizopus sp. pneumonitis with invasion of pulmonary arteries and veins resulting in a large pulmonary infarct in the left upper lobe. Multiple fungal emboli were also noted in the heart apex, thyroid, right kidney, and a hemorrhagic infarction of the right cerebellar hemisphere.
CONCLUSIONS: This case illustrates the importance of a high clinical suspicion for mucormycosis in transplant patients who deteriorate on voriconazole, an agent used primarily for invasive aspergillosis but has no activity against Rhizopus. Recently, a significant increase in the incidence of breakthrough sinopulmonary mucormycosis has been noted among transplant patients on voriconazole prophylaxis. This case underscores the importance of considering mucormycosis in this population so that diagnosis and appropriate treatment can be instituted early to avert the significant mortality associated with this devastating infection.
CLINICAL IMPLICATIONS: A recent increase in mucormycosis has been noted in the last few years in patients in voriconazole prophylaxis. Knowing these patients are at risk can facilitate early diagnosis and treatment to avoid mortality.
DISCLOSURE: The following authors have nothing to disclose: Joanna Paula Sta. Cruz, Sherilyn Tuazon, Lemuel NonNo Product/Research Disclosure Information.

PMID: 24638768 [PubMed - in process]