Additional EBUS-guided intralesional amphotericin B injection combined systemic intravenous therapy in pulmonary mucormycosis: a case report

Abstract

Mucormycosis is an invasive fungal infection that can result in severe lung infections, with pulmonary mucormycosis (PM) being one of the most prevalent manifestations. Prompt diagnosis is crucial for patient survival, as PM often exhibits rapid clinical progression and carries a high fatality rate. Broncho-alveolar lavage fluid or endobronchial biopsy (EBB) has been commonly employed for diagnosing PM, although there is limited mention of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the literature. In this report, we present a case of PM in a patient with diabetes. While EBB did not yield evidence of Rhizopus infection, a definitive diagnosis was obtained through EBUS-TBNA. The patient underwent combination therapy, including oral medication, nebulization, and EBUS-guided intrafocal amphotericin B injection, which resulted in significant improvement following the failure of initial therapy with amphotericin B injection cholesterol sulfate complex. Our case highlights the potential of EBUS-TBNA not only for mediastinal lymphadenopathy but also for obtaining extraluminal lesion specimens. Furthermore, for patients with an inadequate response to mono-therapy and no access to surgical therapy, the addition of EBUS-guided intralesional amphotericin B injection to systemic intravenous therapy may yield unexpected effects.

Keywords: endobronchial ultrasound; liposomal amphotericin B; pulmonary mucormycosis.

Figure 1.

Chest CT showed the consolidation of the right lower lobe.

Figure 2.

Chest CT showed rapid progression within 3 days, with consolidation and surrounding interstitial and ground glass lesions.

Figure 3.

A neoplasm was found at the opening of the basal segment of the RLL. RLL, right lower lobe.

Figure 4.

Abnormal hypoechoic signals outside the lumen of the basal segment of the RLL could be seen and a biopsy was performed through EBUS-TBNA. EBUS-TBNA, endobronchial ultrasound-guided transbronchial needle aspiration; RLL, right lower lobe.

Figure 5.

Pathology showed typical Rhizopus mycelia with positive staining for PAS and GMS. GMS, Grocott–Gomori’s silver; PAS, periodic acid-Schiff.

Figure 6.

Pathology showed typical Rhizopus mycelia with positive staining for PAS and GMS. GMS, Grocott–Gomori’s silver; PAS, periodic acid-Schiff.

Figure 7.

Pathology showed typical Rhizopus mycelia with positive staining for PAS and GMS. GMS, Grocott–Gomori’s silver; PAS, periodic acid-Schiff.

Figure 8.

The culture result of purulent puncture fluid obtained by EBUS at the lesion suggested Rhizopus. EBUS, endobronchial ultrasound.

Figure 9.

Amphotericin B was injected into the lesion through EBUS. EBUS, endobronchial ultrasound.

Figure 10.

Obvious absorption can be seen after combination therapy.