Pulmonary mucormycosis complicated with transplant renal dysfunction: A case report.

CASE HISTORY: Patient is a 60-year-old woman admitted with "intermittent dry cough for 3 months". Past medical history includes hypertension, uncontrolled type 2 diabetes mellitus, status post renal transplantation, and chronic renal insufficiency. Initial investigations at an outside hospital revealed leukocytosis (15.8 × 109/L) with neutrophilia (90.9 %). Chest computed tomography (CT) demonstrated multiple high-density masses with cavitation in the right lung and multilobar micronodules.

SYMPTOMS AND SIGNS: Predominantly dry cough, occasionally accompanied by a small amount of white mucous sputum, accompanied by pharyngeal constriction when coughing violently, profuse sweating and loss of appetite; on examination, the right lung respiratory sounds were coarse, and wet rales were detected, and the rest of the lungs were unremarkable.

DIAGNOSTIC

METHODS

Bronchoscopy revealed obstruction by necrotic material in the posterior segment of the right upper lobe. Rapid on-site evaluation (ROSE) demonstrated broad, aseptate hyphae with irregular wide-angle branching. Histopathological examination of the lung biopsy specimen showed fungal aggregates morphologically consistent with Mucorales (positive on periodic acid-Schiff [PAS] and Grocott's methenamine silver [GMS] stains). Next-generation sequencing (NGS) of bronchoalveolar lavage fluid (BALF) excluded bacterial and mycobacterial infections. Serial chest CT imaging documented a cavitary lesion in the right lung with multilobar nodules.

TREATMENT: Initially, moxifloxacin was given as empirical anti-infection, and after diagnosis, due to combined renal insufficiency after renal transplantation, gradual incremental amphotericin B liposome (5mg→40mg/d) treatment was given, combined with nebulized amphotericin B, which was adjusted to amphotericin B cholesterol sulfate complex due to persistent elevation of creatinine (peak value of 193μmol/L). After discharge from the hospital, due to recurrent disease, he was switched to long-term consolidation with esaconazole (200mg q8h × 2d sequential 200mg qd), combined with beryllium capsules for renal and lung protection.

CLINICAL OUTCOME: Chest CT showed shrinkage of the cavity after 28 days of treatment, and 2-year follow-up showed significant resorption of the lung lesions, reduction of blood creatinine from 245 μmol/L to 129.10 μmol/L, and maintenance of stable renal function.

TARGET AUDIENCE: Transplant nephrology, endocrinology, infectious diseases, and pulmonology specialists.