A69-43 Fungal Fury: A Growing Concern for Immunocompromised Population

Abstract Background Invasive fungal infections (IFI), including mucormycosis, are rare and life-threatening conditions in immunocompromised patients. We present a case of a severely immunocompromised patient with disseminated primary left upper lobe pulmonary mucormycosis. Case A 72-year-old male presents with two weeks of fever, dyspnea and hemoptysis. Past medical history includes recently relapsed acute myeloid leukemia (AML) after failing multiple cycles of chemotherapy and currently receiving enasidenib and prophylactic fluconazole, acyclovir and cefpodoxime. Initial labs showed severe neutropenia with absolute neutrophil count (ANC) of 0. 2 10³/uL, hemoglobin 4. 2 g/dL, platelets 7 10³/uL, creatinine 1. 8 mg/dL, lactate 2. 1mmol/L. Initial chest computed tomography (CT) showed 5. 3 cm left upper lobe consolidation with thickened borders and central clearing (reverse halo sign) which was suspicious for invasive fungal infection. He was started on vancomycin, cefepime and isavuconazole empirically for neutropenic fever and probable pulmonary invasive fungal infection based on radiographic appearance. On hospital day three, CT cervical neck/upper extremity showed new subcutaneous and deeper soft tissue edema in the left supraclavicular region, chest wall and axilla raising suspicion for mucor due to transection of anatomical planes and repeat chest CT showed increased left lung consolidation now throughout the left upper lobe. This prompted transition of isavuconazole to intravenous liposomal amphotericin B dosed at 5 mg/kg/day. On exam, he also developed purple lesions with a central eschar over his left upper extremity. Mucorales PCR was positive. BAL Aspergillus PCR and Nocardia PCR were negative. Serum galactomannan and beta-d-glucan were undetectable. Diagnosis of invasive pulmonary mucormycosis with possible extension into his left shoulder and skin was made. Given continued clinical worsening despite optimal medical therapy, the patient was transitioned to comfort measures only. Discussion Mucormycosis is a rare but severe invasive fungal infection caused by Mucorales with a high mortality rate of up to 80% (1). These fungi are found in decomposing organic matter and soil and can infect humans through inhalation, ingestion or traumatic inoculation (2, 3). Mucormycosis is most commonly seen in immunocompromised hosts with underlying hematologic malignancies, organ transplants or corticosteroid use (4, 5). Primary infection is localized to a single organ system but then can disseminate to others via hematogenous spread. Importantly, serum fungal markers are negative in Mucormycosis. Management includes antifungal therapy and surgical debridement. Conclusion This case aims to highlight a real-life conundrum and high mortality associated with patients with an underlying hematologic malignancy, pancytopenia and Mucormycosis. This abstract is funded by: None