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