Hospital: HOSPITAL UNIVERSITARIO MORALES MESEGUER.
Nº: C2019-408
Aut@r o Autores: G. Pérez Hernández, A. Blanco Barrio, M. Lozano Ros, I. García Tuells, I. Herves Escobedo, I. Vicente Zapata.
Presentación
A 27-year-old woman was admitted with diabetes descompensation secondary to severe community-acquired pneumonia. After 2 weeks in the ICU and no improvement despite broad-spectrum antibiotic treatment, a chest CT scan was performed. It showed extensive areas of central consolidation in the right lung crossing the fissures, right pleural effusion, and left lung perivascular ground glass opacities. The consolidations limites areas of central ground glass opacity (reversed halo sign). Large halo signs were also present. The pulmonary involvement encompassed all of the right lung bronchi, showing amputation of the middle lobe segmental arteries and signs of mediastinal fat involvement, all consistent with an invasive infection. Bronchoscopy and biopsy werw performed with the diagnosis of pulmonary mucormycosis. Despite treatment with antifungals, the consolidations suffered necrosis and cavitation. Left lung involvement also worsened. Signs of vascular invasion evolved into irregularity of the lobe pulmonary arteries, stenosis, dilation and pseudoaneurysm formation. She developed severe haemoptysis with rapidly progressing clinical deterioration and died.
Discusión
Pulmonary mucormycosis is an opportunistic aggressive fungal infection, much less common than Aspergillus and Candida infections, and with a much higher mortality rate. It is an angioinvasive infection often leading to pulmonary infarction and invasion of tissues by contiguity. It can manifest as a reverse halo sign on CT, consistent with a thick solid area of consolidation with central ground glass opacity, a frequent and relatively specific sign of mucormycosis in the appropriate clinical setting. Vascular findings include arterial filling defects (fungal emboli) and pulmonary artery pseudoaneurysm formation due to direct invasion of the arterial walls. In this sense, the vascular cutoff sign refers to an abrupt termination of a branch of the pulmonary artery. Some severe cases may show a pattern of multifocal pneumonia, which is associated with high mortality and simulates multifocal bacterial pneumonia. Mucormycosis usually occurs in patients with hematologic malignancies, particularly after a stem cell transplant. Nowadays, diabetes mellitus as an isolated risk factor, as in our case, is very rare.
Conclusión
Pulmonary mucormycosis is an uncommon, usually fatal, opportunistic infection, oftenmanifesting with the reverse halo sign on CT, which is highly specific for the disease in the appropriate clinical setting. It may also cross pleural surfaces and invade vascular structures and tissues by contiguity. Diabetes today, as the only risk factor, is very uncommon.
Bibliografía
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