2 | CLINICAL PRESENTATION
A 66-year-old male smoker (10 pack/ year), known diabetic, and recently
diagnosed case of decompensated cirrhosis of the liver was admitted to
the Department of Respiratory Medicine of BSSMU with fever, cough, and
shortness of breath for 2 weeks. There was no history of chest pain,
skin rash, bony tenderness, epistaxis, hemoptysis, or weight loss.
The patient denied any history of steroid intake or contact with smear
positive pulmonary tuberculosis patient. Physical examination revealed
the patient was anemic, non-icteric, generalized clubbing without
hypertrophic pulmonary osteoarthropathy, multiple spider naevi over the
chest, and cervical lymphadenopathy were present. However, vitals were
within the normal limit. Respiratory system examination had normal
findings, and abdominal examination revealed ascites and small testes
without any organomegaly.
Laboratory investigation showed hemoglobin 9.9 g/dl, total WBC count
3500 cells/cumm, and platelet 1 lakh/cumm. Biochemical investigation
revealed serum creatinine 0.93 mg/dl, CRP 12.89 mg/dl, RBS 11.7 mmol/L,
HbA1c 9.0 %, Bilirubin 1.4 mg/dl, Albumin 26 gm/dl. Serum electrolytes
and liver function tests were normal. Ultrasonography of the whole
abdomen showed chronic parenchymal liver disease with splenomegaly with
features suggestive of portal hypertension, and mild ascites (600ml).
Upper GIT endoscopy showed- Grade ΙΙΙ esophageal varices with severe
portal hypertensive gastropathy.
Chest X-ray showed- left-sided cavitary lesion and right-sided
consolidation with basal pleural effusion [Figure 1]. Sputum microbiological investigation for gram staining revealed - a
moderate number of gram-positive cocci arranged in clusters and short
chains with a moderate number of pus cells. Culture and sensitivity
reports showed profuse growth of Klebsiella spp. and fungal stain showed
budding yeast cells with pseudo-hyphae. Sputum for AFB, Gene X-pert
MTB/RIF, and malignant cells were negative. HRCT of the chest showed a
bilateral upper lobe cavitary lesion with a right-sided minimal pleural
reaction suggestive of abscess [Figure 2] .
According to the culture and sensitivity, the patient was put on
intravenous ceftriaxone 2gm twice daily and tab itraconazole 400 mg/day
for 14 days respectively without any response. Ascitic fluid aspiration
was also performed which showed lymphocytic (90%) predominant exudative
(protein 13.08 g/dL, albumin 5.38 g/dL) ascitic fluid with normal ADA
(6.51 U/L). ascitic fluid AFB and Gene X-pert MTB/RIF were also
negative. For further evaluation, fine needle aspiration cytology (FNAC)
from the left cervical lymph node was performed that revealed- discrete
and non-caseating epithelioid granulomata containing foreign body type
as well as Langhans type giant cells, focal hyalinization of the stroma
present, finding consistent with non-granulomatous lymphadenitis.
For further evaluation, a CT-guided biopsy from the left cavitary lung
lesion was done. Microscopic examination of the biopsy specimen revealed
an area of infarction with surrounding fibrofatty tissue containing
broad non-septate hyphae with right-angled branching [Figure
3] and positive for GMS staining [Figure 4] compatible
with mucormycosis. Gene X-pert MTB/RIF and culture for MTB of the biopsy
tissue were negative.
After confirmation of a diagnosis of pulmonary mucormycosis, the patient
was counseled about the treatment protocol. The patient was financially
constrained to bear the expense of Liposomal amphotericin B therefore we
started tablet posaconazole (Xpos) 300mg twice daily on Day 1 followed
by 300mg daily for 3 months. Consultations from the hepatologist and
endocrinologist were obtained regarding the optimal management of
chronic liver disease (CLD) and diabetes mellitus and managed
accordingly. After one month of follow up patient symptoms amended with
nearly the complete resolution of the chest X-ray finding[Figure 5] without any documentation of side effects.
During the end of three months of treatment, the patient was
asymptomatic with complete resolution of chest x-ray findings