Management of Pulmonary Mucormycosis After Orthotopic Heart Transplant: A Case Series

Abstract

Invasive pulmonary mucormycosis is a potentially fatal infection that can occur in immunosuppressed patients such as those who have undergone orthotopic heart transplant (OHT). High-dose intravenous antifungal agents, including amphotericin B, are generally accepted as the first-line medical treatment, with prompt surgical resection of lesions if feasible. The body of evidence guiding treatment decisions, however, is sparse, particularly regarding adjustment of immunosuppression during acute infection and long-term recovery. We present 2 cases of patients with pulmonary mucormycosis occurring within the first 6 months after OHT, both of whom successfully recovered after appropriate medical and surgical treatment, and we highlight differences in immunosuppression management strategies for this life-threatening condition.

Fig 1.

Chest computed tomography (CT) in case 1 shows (A and B) right upper lobe lesion with maximum diameter of 6.5 × 7.3 cm and (C and D) resolution of the lesion after medical and surgical management. (E) Hematoxylin and eosin (H&E)-stained section (original magnification, ×10) of a CT-guided biopsy sample showing areas of necrosis (N) with surrounding viable tissue with marked inflammation, including giant cells (arrowheads). Several ribbon-like hyphae (arrows) are present in both the necrotic region and the viable region. (F) H&E-stained section (original magnification, ×40) of a biopsy specimen showing detail of hyphae in a background of necrotic tissue. The morphology is consistent with Mucorales genera.

Fig 2.

Chest computed tomography in case 2 showing (A) right upper lobe lesion measuring 3.1 cm in diameter, (B) cavitary right lower lobe lesion measuring 7.4 cm in diameter and exhibiting “reverse halo” sign, (C) left lower lobe lesion measuring 3.1 cm, and (D) small area of left lower lobe atelectasis remaining after 19 months of posaconazole therapy. (E) H&E- and (F) Gömöri methenamine silver−stained sections demonstrating hyphae with fungal infiltration of vessel walls, characteristic of Mucorales.