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The patient, a 6-year-old male, was admitted to the hospital 6 months ago due to abdominal pain and high fever, suspected of tuberculosis, and was discharged after 6 months of treatment with isoniazid and vitamin B6, but his condition did not improve
Laboratory tests showed that the patient had a negative serological test for hepatitis B and C; QuantiFERON-TB Gold test is negative
The patient's chest x-ray shows a right pleural effusion (Figure 1); Chest puncture shows chylothosa (exudative pleural effusion), and direct microscopic examination of lung aspirants after lactate cotton blue staining (LPCB) reveals no septal hyphae, clustered, branched sporangia and rounded sporangia at the apex, indicating fungal infection of the genus Rhizobium (Mucormyceae) (Figure 2).
Figure 1 patient chest x-ray shows a right pleural effusion
A
B
Figure 2A Fungi of the genus Rhizobium were found in the patient's lung aspirate, showing sporangia (green arrows) and sporangia (red arrows); B Fungi of the genus are found in the patient's renal cyst aspirate
Figure 3 CT of the abdomen shows a large renal cyst on the left (red arrow) with hydronephrosis
On the fifth day after admission, the patient developed a new pulmonary effusion, cervical lymphadenopathy, hypoalbuminemia, and fever
CGD is a rare hereditary immunodeficiency disease in which phagocytes (a type of white blood cell) do not work
Mucormycosis is a rare but serious disease
According to the clinical manifestations and the site of infection, mucormycosis is mainly divided into 6 types: nasocerebral type, pulmonary type, skin type, gastrointestinal type, renal type, and disseminated type
.
In this patient, both lung and kidney infections were present
.
Pulmonary mucormycosis is clinically manifested by fever (> 38°C), shortness of breath and cough; Renal mucormycosis is usually characterized by fever, flank pain, hematuria, or anuria
.
Mucormycosis is susceptible to misdiagnosis
due to its non-specific clinical symptoms and radiological features.
The currently internationally accepted diagnostic criterion is the finding of characteristic hyphae in biopsy tissues and having a clear pathomorphological feature
.
Due to the fragility of the mucormycete hyphae, the culture sensitivity is poor, and the hyphae are often destroyed
during specimen collection.
As a result, only about one-third of positive specimens produce positive results
under the microscope.
The patient in this case had previously been nearly misdiagnosed with tuberculosis
.
Therefore, clinical suspected cases should pay attention to improving the examination and distinguishing it
from other diseases.
The 2019 global guidelines for the diagnosis and management of mucormycosis recommend high-dose amphotericin B liposomes as first-line therapy, while intravenous esaxonazole and posaconazole or treatment with posaconazole extended-release tablets are recommended as moderate-intensity therapy
.
At the same time, studies have proven that interferon-γ is effective in preventing serious bacterial and fungal infections, especially in patients with
CGD.
epilogue
Mucormycosis can pose a life-threatening condition, especially in children, if not diagnosed and treated in a timely manner, and in immunocompromised patients, the disease often progresses and can be fatal
.
In the post-epidemic era, the incidence of rare invasive mucormycosis with a high case fatality rate has increased significantly, but there is currently no effective vaccine against mucormycosis, so rapid diagnosis, timely intervention and treatment measures are the key
to improving recovery.
The diagnosis and treatment of mucormycosis requires multidisciplinary and multi-departmental collaboration, and patients with suspected mucormycosis should immediately take the highest level of care, and complete imaging, fungal pathogens and molecular biology examinations early to prevent delays in diagnosis
.
References:
1.
Opara, N.
U.
A Rare Case of Pulmonary and Gastrointestinal Mucormycosis Due to Rhizopus spp.
in a Child with Chronic Granulomatous Disease.
Infect.
Dis.
Rep.
2022, 14, 579-586.
2.
Yanmei Jiao, Yunhui Zhang, Yalin Zhao, Zhengran Chuan, Yao Sun, Fusheng Wang.
Review of important epidemic events of global infectious diseases in 2021[J].
Infectious Disease Information,2022,35(01):27-38.
3.
Zhao Jingyu,Fang Wei,Pan Weihua,Liao Wanqing.
Prevention and control strategies and research progress of mucormycosis[J].
Microorganisms and Infection,2021,16(05):291-297.
4.
Feng Ziqing,Jin Ling,Fu Libing,Zhang Ningning,Duan Yanlong.
A case of non-Hodgkin lymphoma complicated with mucormyces pneumonia in children[J].
Chinese Journal of Pediatric Hematology and Oncology,2022,27(03):204-205+217.
5.
Cornely OA, Alastruey-Izquierdo A, Mucormycosis ECMM MSG Global Guideline Writing Group et al.
Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.
Lancet Infect Dis.
2019 Dec; 19(12):e405-e421.