Three case reports of pulmonary mucormycosis with a review of the literature

Abstract

Pulmonary mucormycosis (PM) is an invasive and life-threatening fungal infection that predominantly affects immunocompromised individuals. This study thoroughly examined the disease through three case reports and a literature review. Case 1 involved a patient with type 1 diabetes mellitus diagnosed through bronchoscopic histopathology, who succumbed despite a combination of oral isavuconazole, nebulized amphotericin B, and intravenous amphotericin B cholesteryl sulfate complex. Case 2 involved a patient with follicular non-Hodgkin lymphoma who had a concurrent coronavirus disease 2019 (COVID-19) infection, which was confirmed through metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF). The patient experienced clinical improvement following sequential intravenous voriconazole, amphotericin B cholesteryl sulfate complex, and oral isavuconazole. Case 3 involved a patient diagnosed with mNGS in a lung cancer patient with chronic obstructive pulmonary disease, who showed poor therapeutic response to combined intravenous voriconazole, amphotericin B cholesteryl sulfate complex, and oral isavuconazole, resulting in fatal outcomes. Literature synthesis revealed mortality rates of 28.3% with antifungal monotherapy compared to 23.7% when antifungal monotherapy was combined with bronchoscopic intervention; the mortality rate for antifungal-surgical combination therapy was 9%. Notably, all 13 patients receiving multimodal treatment (antifungals, bronchoscopy, and surgery) survived. These findings underscore that combination therapy integrating pharmacotherapy, bronchoscopic intervention, and surgical resection demonstrated significantly superior survival outcomes compared to monotherapy.

Keywords: amphotericin B; bronchoalveolar lavage; case report; literature review; pulmonary mucormycosis.

Figure 1

Chest CT of Case 1. Computed tomography (CT) of the chest before the start of treatment (a,b) Multiple flaky, glassy, nodular hyperdense shadows in both lungs, partly solid, especially in the upper lobe of the right lung, with cavity formation. Post-treatment chest CT (c,d) The inflammation is more absorbed than before, but cavities remain.

Figure 2

Temperature chart and medication chart for Case 1.

Figure 3

Chest CT of Case 2. Computed tomography (CT) of the chest before the start of treatment (a,b) large, patchy high-density foci under the pleura of the right lung with blurred margins and uneven density. Chest CT after 2 months of continuous treatment (c,d) Flocculent and patchy slightly high-density foci were seen under the pleura of the lower lobe of the right lung, with fuzzy edges and uneven densities, which were significantly better than before.

Figure 4

Temperature chart and medication chart for Case 2.

Figure 5

Chest CT of Case 3. Computed tomography (CT) of the chest before the start of treatment (a,b) Multiple scattered patchy high-density lesions were seen in both lungs, some of which were ill-defined and mostly solid, and bronchial air phases were seen within some of the lesions. Chest CT after exacerbation (c,d) A small amount of pericardial effusion was seen, and arcuate watery density shadows were seen in both thoracic cavities.

Figure 6

Temperature chart and medication chart for Case 3.