The author of this article is Xu Zhiyang, attending physician of the Department of Infectious Diseases, Second Hospital of Zhejiang University
The 70-year-old uncle fell down, but found a large hole in his lungs and "ink"?
Recently, Xu Zhiyang, an attending physician in the Department of Infectious Diseases at the Second Affiliated Hospital of Zhejiang University School of Medicine (hereinafter referred to as the Second Affiliated Hospital of Zhejiang University), encountered such a case.
A 70-year-old man with prior leukemia was hospitalized in an outpatient hospital for COVID-1 COVID. After being discharged from the hospital a few days ago, he accidentally fell and suffered a femoral neck fracture, and was admitted to the Department of Orthopedics of the Second Hospital of Zhejiang University.
Soon, however, the orthopedic surgeon called the Department of Infectious Diseases: the patient's preoperative routine chest CT image showed a large thick-walled cavity in the lungs, 62*44mm in size, and it was necessary to distinguish an abscess with cavitation or neoplastic lesions.
Chest CT on the day of patient admission
The Department of Infectious Diseases quickly judged that orthopedic surgery should be suspended immediately and the patient should be transferred to a department for further diagnosis.
The lungs are huge cavities, and the drainage fluid is blacker than ink
On the day of the transfer, an accident occurred. The patient vomited 300 mL of coffee-coloured gastric contents, and the blood count showed a decrease in both hemoglobin and platelets.
The Department of Infectious Diseases quickly contacted the Department of Gastroenterology for emergency gastroscopy, but no signs of active bleeding were found.
So, could these "vomited" coffee-coloured objects be old pulmonary hemorrhages?
The Department of Infectious Diseases urgently gave blood transfusion and hemostasis to stabilize the patient's condition, and contacted the chief physician of the Department of Respiratory Medicine, Ding Liren, and asked the anesthesia and surgery department to consult to see if tracheoscopy could be performed for the patient to further clarify the cause. However, considering that the patient's general condition is poor, platelets are low, and the patient is in the recovery period of new crown pneumonia, and the lung function may decline compared with before, the anesthesiology and operation department believes that the patient is at a greater risk of general anesthesia and recommends that the tracheoscopy be suspended.
The patient presents with hemoglobin and platelet changes at 1 week after transfer to the Department of Infectious Diseases
There must be an etiological basis for precise treatment. The Division of Infectious Diseases has proposed another option: CT under local anesthesia to guide percutaneous lung puncture and catheter drainage.
After discussion with the radiology department and communication with the patient and family, Xu Zhiyang performed a puncture of the left lung abscess and drainage bag under CT guidance, and a total of about 90ml of fluid was drained on the same day.
However, when he saw the color of the drainage fluid, Xu Zhiyang's mind suddenly became alarmed: the liquid in the patient's drainage bag was even darker than "ink"!
The patient's drainage fluid is blacker than ink
Lock the real culprit, the mortality rate is as high as 70~100%
Before coming to the Second Hospital of Zhejiang University, the patient had been hospitalized in an external hospital due to new coronary pneumonia, and the original lesion of chest CT was significantly improved before discharge, but there was a new abscess. At that time, the hospital considered pulmonary aspergillus infection and ordered oral "voriconazole".
However, the patient's condition continued to progress. This made the doctors in the infectious disease department nervous.
After communicating with the patient's family, Xu Zhiyang immediately sent the "ink"-like drainage solution to microbial culture and high-throughput sequencing (NGS). The results of the examination revealed a more terrible mold than Aspergillus - Rhizopus.
NGS test results and microbial culture results
Rhizopus is a type of mucor mold. Mucormyces is a class of ubiquitous fungi that are usually found in soil, decaying organic matter, compost and contaminated food, and can cause infection of nasal-orbital-brain, lung, subcutaneous and other tissues through respiratory inhalation, direct contact with skin wounds, or absorption of the gastrointestinal tract.
Pulmonary mucormycosis is an acute purulent lung disease caused by the order Mucormycetes, and chronic infection is rare. Clinically, mucormycetes and rhizopus are more common. This disease has a poor prognosis, causes thrombosis and necrotizing changes, forms a cavity and produces hemoptysis when the lung parenchyma is involved, and can cause fatal massive hemoptysis when large blood vessels are involved, which is an important cause of mortality [1].
Rhizopus mycelium, hyphae, and spores
Mucormycosis infections are more common in patients with immunodeficiency disorders, particularly in patients with diabetes and hematologic malignancies with poor glycemic control. Lung infections are more common in patients with hematologic malignancies or organ transplants. If the treatment is not timely, the mortality rate can reach 70~100%.
The 70-year-old patient, who had previously undergone nine chemotherapy treatments for acute myeloid leukemia and hormone therapy for COVID, were all high-risk factors for pulmonary mucormycosis.
Adverse drug reactions are serious, how to solve them?
Because mucormycosis symptoms are atypical, early diagnosis and early treatment are crucial. Fortunately, the Department of Infectious Diseases has bought back a lot of time for patients in the diagnosis process.
The next question is, how is it treated?
Currently, treatment for mucormycosis infections includes both medical and surgical treatments. Surgical treatment includes debridement, resection of localized lung lesions, and amphotericin B is the preferred medical treatment.
Amphotericin B is the most extensive and active antifungal drug in clinical practice. However, at the same time, amphotericin B has many side effects, such as acute infusion reactions (chills, fever, etc.), hypokalemia, kidney damage, arrhythmia, etc., and some patients will have serious side effects such as allergies and nephrotoxicity.
Source: Expert Consensus on Clinical Diagnosis and Treatment of Mucormycosis in China (2022)
Chief Physician Xu Feng of the Department of Infectious Diseases immediately organized the Department of Respiratory Medicine, Department of Thoracic Surgery and other related departments to discuss the treatment plan.
Ding Liren, chief physician of the Department of Respiratory Medicine, Wang Xuanding, director of the Office of Antimicrobial Drugs and Rational Medication, and Liu Jin, chief physician of the Department of Infectious Diseases, agreed that the prognosis of mucormycetes is poor, the treatment plan is complex, and the treatment of voriconazole in the patient's hospital is ineffective, and it is recommended to treat amphotericin B first.
Given the side effects of amphotericin B, experts recommend a gradual increase in dose, taking into account the patient's own tolerance.
Sure enough, after taking amphotericin B, the patient developed symptoms of refractory hypokalaemia and chest tightness. When the cumulative intravenous dose was 730mg, the patient did not improve the above symptoms.
Chief Physician Xu Feng suggested suspending the intravenous infusion of amphotericin B and replacing it with nebulized inhalation and tracheoscopic instillation of amphotericin B, and at the same time adding the combination therapy of the second-generation triazole antifungal drug - isaconazole, which successfully solved the problem of adverse reactions of patients.
Swipe left and right to see all images: Chest CT at the time of initiation of amphotericin B therapy, on day 4 of isavuconazole initiation of treatment, 1 month after isavuconazole initiation of treatment, and 2 months and 20 days after isavuconazole initiation of treatment
After 3 months of treatment, the patient's chest CT lesions were significantly smaller and stable on follow-up chest CT than before. After discharge, continue to take isavuconazole orally and follow up regularly.
Case Interpretation: Xu Feng, Chief Physician, Department of Infectious Diseases, Second Hospital of Zhejiang University Interpretation: Pulmonary mucormycosis is a conditionally pathogenic fungal disease caused by mucormycosis infection, which mainly affects immunosuppressed people, such as diabetic patients, malignant tumor patients, etc. The patient in this case has a history of leukemia and is a susceptible group to pulmonary mucormycosis. In the past, the etiological diagnosis of pulmonary mucormycosis mainly relied on histopathology and microbial culture, but pathology requires biopsy to obtain qualified specimens, and the positive rate of culture is low. In this case, the combination of NGS detection and culture of chest drainage fluid was used to identify Rhizopus infection in a timely manner, which has important guiding significance for follow-up diagnosis and treatment. First-line treatment for pulmonary mucormycosis is amphotericin B (deoxycholate or lipid preparation), with isavuconazole and posaconazole, or a combination of surgery and topical therapy. Treatment with intravenous amphotericin B was poorly tolerated and was subsequently switched to nebulized amphotericin B nebulized inhalation and tracheoscopic local perfusion, combined with oral isavuconazole. Combination therapy has been shown to be more effective and has reduced the side effects of amphotericin B. Pulmonary mucormycosis is atypical, difficult to diagnose, and often has a poor prognosis. In this case, the pathogen was identified in a timely manner, and good treatment results were achieved through drug combination therapy.
Source: Lilac Garden (O31)