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Sudden death in a patient with bone marrow transplant by a fungus among us
Lemuel Non1, Joanna Paula Sta Cruz2, Sherilyn Tuazon3
1Department of Infectious Diseases, Washington University in St. Louis/ Barnes-Jewish Hospital, St Louis, Missouri, USA.
Abstract:
Mucormycosis is rare, presenting as breakthrough infection among haematological and transplant patients on prophylaxis with voriconazole. We report an unusual presentation of this infection, that which is pneumonia progressing to cardiac arrest. A 68-year-old woman with refractory acute myelogenous leukaemia on voriconazole prophylaxis was initially admitted for neutropenic fever and pneumonia. She was discharged improved on antibiotics and voriconazole for presumed aspergillosis. She returned after 1 month with the same presentation. She eventually improved on antibiotics and voriconazole, and eventually received bone marrow transplantation. Three days later, she developed pleuritic chest pain, dyspnoea, and hypoxia requiring intubation. An hour after intubation, the patient arrested and expired. Autopsy revealed Rhizopus pneumonitis with pulmonary infarction, and emboli to her cerebellum, heart, thyroid and kidney. Mucormycosis is an emerging, fatal infection that should be suspected in haematological and transplant patients who deteriorate on voriconazole.
Insights
Mucormycosis, a rare fungal infection, can present as pneumonia in immunocompromised patients. This case highlights a fatal outcome in a leukemia patient despite voriconazole treatment, emphasizing the need for high suspicion.
Area of Science:
- Mycology
- Infectious Diseases
- Hematology
Background:
- Mucormycosis is a rare, invasive fungal infection.
- It often presents as a breakthrough infection in immunocompromised patients, including those undergoing chemotherapy or transplantation.
- Voriconazole prophylaxis is common in these patients, but breakthrough infections can still occur.
Observation:
- A 68-year-old woman with acute myelogenous leukemia on voriconazole prophylaxis presented with recurrent pneumonia.
- Despite initial improvement and bone marrow transplantation, she developed respiratory distress and cardiac arrest.
- Autopsy confirmed Rhizopus pneumonitis with widespread embolization.
Findings:
- The patient's pneumonia progressed to fatal outcomes, including cardiac arrest.
- Autopsy revealed pulmonary infarction and emboli in multiple organs, consistent with disseminated mucormycosis.
- This case demonstrates an unusual and severe presentation of mucormycosis.
Implications:
- Mucormycosis should be suspected in hematological and transplant patients who deteriorate clinically, even while on voriconazole.
- Early and accurate diagnosis is crucial for improving outcomes in these high-risk patients.
- This case underscores the limitations of voriconazole prophylaxis against certain fungal pathogens in severely immunocompromised individuals.
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