Pseudoaneurysm of Pulmonary Artery in Mucormycosis: Radiographic Characteristics and Management

Abstract

Pulmonary mucormycosis is a rare and almost invariably fatal complication that can occur in the context of severe deficits in host defenses. Antemortem diagnosis is difficult and requires a high index of suspicion together with invasive diagnostic techniques. Mucor species exhibit a pronounced affinity to invade vessels; mucormycosis involving the pulmonary vasculature has rarely been documented antemortem, and survival in this context has been rare. In this report, we describe a patient with chronic renal failure and systemic lupus erythematosus who developed extensive invasion of the left main pulmonary artery by mucormycosis. Chest computed tomographic (CT) scans and pulmonary arteriogram demonstrated a massive pseudoaneurysm of the left pulmonary artery; these radiographic findings have not previously been described in mucormycosis. Aggressive combination therapy, employing preoperative amphotericin B (AmB) followed by surgical resection (pneumonectomy) and a full course of AmB, was curative. This favorable outcome supports the role of surgery as adjunctive therapy, and it underscores the need for early diagnosis and aggressive treatment.

Mucormycosis

“…A B C D 173 ; and bronchopleural fistula. 8,69,105,179 Invasion of pulmonary vessels may result in necrotizing pneumonia 78 ; pulmonary arterial aneurysms 180 ; fatal aortic rupture 181 ; and fatal hemoptysis. 23,177,182,183 Invasive ulcerative tracheobronchitis at the anastomotic site in lung transplant recipients is much more common with Aspergillus spp., but Rhizopus tracheobronchitis has been described.…”

“…23,78 For localized PulM, surgical resection (coupled with medical therapy) may be lifesaving. 180,190,191 Invasive tracheobronchitis due to Mucorales or other molds in mechanically ventilated patients in intensive care units (ICUs) with overall mortality of 93.5% has been described. 192 In this cohort, 58% had DM and 39% had chronic lung disease.…”

Fungal Infections Complicating Lung Transplantation

“…5). Invasion of pulmonary vessels may result in necrotizing pneumonia, 38 pulmonary arterial aneurysms, 193 and hemoptysis (even fatal). 114,194 Invasive ulcerative tracheobronchitis at the anastomotic site in LTRs is much more common with Aspergillus spp., but Rhizopus tracheobronchitis has been described.…”

“…38,114 For localized pulmonary mucormycosis, surgical resection (coupled with medical therapy) may be lifesaving. 193 Invasive tracheobronchitis due to Mucorales or other molds in mechanically ventilated patients in intensive care units (ICUs) with overall mortality of 93.5% was recently described. 196 In this cohort, 58% had diabetes mellitus and 39% had chronic lung disease.…”

“…32 Surgery is particularly useful for rhinocerebral, 147 skin and soft tissue disease, 191 and in some cases for localized pulmonary disease. 125,193,194 In a review of 90 cases of ROCM among SOT recipients, overall mortality was 52%. 147 Factors associated with improved survival included: use of LFAB (instead of AmB deoxycholate; OR: 0.09, p ¼ 0.006) and surgery (OR: 0.12, p ¼ 0.04).…”