Ann Thorac Surg 2003;75:1332
© 2003 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Invasive pulmonary mucormycosis with ruptured pseudoaneurysm
James Merlino, MDa,
R. Thomas Temes, MDb*,
Nancy E. Joste, MDc,
Inderjit S. Gill, MDb
a Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
b Department of Cardiothoracic Surgery, The Cleveland Clinic, Cleveland, Ohio, USA
c Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
* Address reprint requests to Dr Temes, The Cleveland Clinic, Department of Cardiothoracic Surgery, 2500 MetroHealth Dr, Cleveland, OH 44109, USA.
e-mail: temest{at}ccf.org
A 67-year-old man presented with a dry cough. His medical history was notable for diabetes, prior cadaveric kidney transplantation, and immunologic suppression with daily prednisone and FK-506.
Admission chest radiography demonstrated a pulmonary infiltrate. Subsequent bronchoalveolar lavage cultures were positive for methicillin-resistant Staphylococcus aureus. Despite antibiotics he developed hemoptysis, increasing infiltrates, and an enlarging left-sided pleural effusion. Chest computed tomographic scan demonstrated a large, heterogeneous intraparenchymal pulmonary mass consistent with a hematoma and free intrapleural fluid (Fig 1).
Pulmonary arteriography confirmed the diagnosis of pseudoaneurysm of the pulmonary artery (Fig 2).
During the operation, the pleural space was filled with fresh clot. Proximal control of the pulmonary artery, followed by evacuation of hematoma and left lower lobectomy with lingulectomy were performed. The large defect in the pulmonary artery was excised with the specimen, and the vessel was transected through grossly normal tissue. An intercostal muscle flap was used to separate the arterial and vascular closures. Intraoperative cultures were positive for methicillin-resistant Staphylococcus aureus, Enterococcus faecalis, and zygomyces. Pathologic work-up demonstrated invasive mucormycosis within the arterial walls. Figure 3
shows a cross-section of pulmonary artery with fungal hyphae invading wall (Gomori 61 second methemamine silver stain, original magnification x500). He was treated with antibiotics, amphotericin B, discontinuation of immunologic suppression, and hemodialysis. He was discharged from the hospital on postoperative day 26.
Mucormycosis is an opportunistic invasive fungal infection generally affecting immunocompromised patients [1–3]. Classic presentation is a cavitary pulmonary lesion on chest radiograph [2]. Invasion into surrounding structures including vessels and bronchi is common. Pseudoaneurysm develops after invasion and contained rupture of a pulmonary vessel. Diagnosis is usually delayed and frequently is established postmortem [1, 2]. Upon diagnosis amphotericin B should be started immediately [3]. Resection of localized disease improves survival, but despite aggressive treatment the mortality rate still approaches 80% [4].
References
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- Coffey M.J., Fantone J., 3rd, Stirling M.C., Lynch J.P., 3rd Pseudoaneurysm of pulmonary artery in mucormycosis. Radiographic characteristics and management. Am Rev Respir Dis 1992;145:1487-1490.[Medline]
- Miller J.A. Pulmonary mucormycosis. Chest Surg Clin North Am 1993;3:699-705.
