Invasive mucormycosis presenting as necrotizing tracheitis, pneumonia and laryngitis treated with liposomal amphotericin B followed by posaconazole maintenance therapy
23 February 2017 (online)
Invasive mucormycosis is a rare opportunistic infection caused by funghi belonging to the order of the ubiquitous mucorales. Clinical guidelines for its diagnosis and management were published in 2014. Surgical intervention in addition to liposomal amphotericin B is recommended as first line therapy. Outcome has improved notably during the last decades but mortality rates remain high.
A 74-year old man was referred to us for evaluation of a persisting pulmonary infiltrate and high C- reactive peptide (CRP) serum level. He had received repeated empiric antibiotic regimens for pneumonia. The patient had a history of autoinflammatory fever syndrome and was on prednisolone therapy (5 mg/day). Bronchoscopy showed longitudinal necrotic alteration of the trachea comprising the lower two thirds of the pars membranacea and involvement of the larynx. Histopathology revealed invasive mucormycosis. A surgical approach did not seem helpful because of multifocal disease manifestation. Antifungal treatment was started with liposomal amphotericin B but had to be discontinued after 6 weeks due to severe complications. We established an oral maintenance therapy with posaconazole. 8 weeks later, the patient presented in a good condition and endoscopic and radiological findings had resolved.
We describe and demonstrate the radiological, endoscopic and histopathological features of this case and conclude that in an immunocompromised patient with pulmonary infiltrates not responding to antibiotic therapy, mucormycosis has to be considered. Since various antimycotic agents including voriconazole are not effective, it is important to discriminate mucormycosis from other invasive fungal infections. Medical treatment can be successful even when severe, necrotizing tracheobronchial lesions are present, yet optimal duration of treatment and likelihood of recurrence are not known.