Post-COVID Pulmonary Mucormycosis-A Case Report

1. Abstract Pulmonary mucormycosis, a relatively rare fungal lung disease,is difficult to diagnose. It is increasingly reported immuno-compromised patients that inhale fungal spores in the air or paranasal sinus, resulting in pulmonary mucormycosis. We report a case of 45 years old patient, with a medical history of hypertension and chronicbronchialdisease.HewasaffectedwithSevereAcuteRespiratory Syndrome CoroVirus 2 (SARS-CoV-2) two months ago hospitalizedinintensivecareforacuterespiratoryfailurewithhis- tory of dyspnea, fever and hemoptysis for one month.

Keywords: Mucormycosis; Mucorales; pulmonarymucormycosis; Intensive care; CT scan

2. Introduction Pulmonary mucormycosis usually occurs in uncontrolled, immunocompromiseddiabeticpatientsandisanopportunisticandfatal fungal disease [1].The severe COVID-19, requiringadmission to intensive care may be considered as an immunodeficiency situation due to the cytokine storm caused by the SARS CoV-2 virus ofpartandadministratedtherapeuticsfromotherparts(Steroids, Anti IL-6 ...) [2].The diagnosis of pulmonary mucormycosis is particularly difficult and it is based on the combination of predisposingfactors(immunodepression,diabetes,chronicrenalfailure, etc.), radiology and mycology tests which leads to an under-estimation of the incidence of this disease [3].

3. Case Report A45-year old male, diabetic at the stage of degenerative complications,hypertensive,andchronicbronchialdisease.Hepresented a history of COVID-19 pneumonia with severe acute respiratory distresssyndrome (ARDS) twomonthsago,which required hospitalization in intensivecare and which progressed well under medical treatment and optiflow; hereceived dexamethasone 6mg/ dfor ten days. After two weeks, the patient presented dyspnea, hemoptysis and fever for aduration of onemonth. Athoracic CT scandones howed a 56mm left perihilar excavated opacity exerting a mass effect on the stem bronchus with the presence of a parenchymal focus of atelectasis and homolateral apical retractile alveolar infiltration, a second right posterobasalexcavatednoduleandasmallleftpleural effusion (Figure 1). Initially, the diagnosis of pulmonary tuberculosis was evoked but sputum cultures were negative, then the patient received antibiotic treatment. However,thesymptomsnotimproved,andhedevelopedasevere hypoxemia.Thus,hewasadmittedinICUandinvasiveventilation wasrequired.Bacteriologicalresultswereinconclusivewhichled to complete with a lung biopsy, which showed broad non-septate fungalhyphaewithmorphologysuggestiveofmucormycosis.

4. Discussion Since emerging cases of COVID-19 pneumonia have spread worldwide,therehavebeenmanyreportsoftheoccurrenceoffungalinfections,particularlypulmonaryaspergillosis,mucormycos- es being less frequent. In most reported clinical cases, pulmonary mucormycosis is a life-threatening fungal infection requiring extensive medical and surgical treatment. In a review of 101 Mucuormycocis infections associated with COVID-19,80%oftheinfectedpatientshadpre-existingdiabetes, mostofthempoorlycontrolledasinourcase[4].Severaldifferent factorsinCOVID-19appeartoaccountfortheincreasedincidence oftheseco-infections.Forexample,COVID-19patientswhoalso haveahistoryofdiabetes,new-onsethyperglycemia,orsteroid-induced hyperglycemia have elevated glucose levels that promote theenvironmentnecessaryforMucoralessporestogerminate[4]. The clinical manifestations are non-specific and commonly include fever, cough, chest pain, dyspnea and hemoptysis, since these pathogens can erode blood vessels [5].Radiological manifestations include infiltrates, exudation, consolidation, cavities and nodules, while the disease typically has a predilection for the upper lobes [6]. Early diagnosis and treatment with the antifungal of reference (Amphotericin) are mandatory to improve the prognosis. In our reported case, the fatal outcome is partly related to the delay in diagnosis prior to admission to intensive care. In the case of antibiotic treatment failure; in the presence of a SARS-CoV-2 history pneumonia and uncontrolled type 2 diabetes, fungal pneumonia must be considered namely the pulmonary mucormycosis.Insuchcases,urgentbronchoscopyshouldbeperformed in order to initiate early appropriate treatment.

5. Conclusion This case report highlights the need to be aware that pulmonary mucormycosismaypresentasasecondarycomplicationofCOV- ID19 co-infection in diabetic patients and to make the diagnosis early in order to improve the prognosis.

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Ahlem Trif. Post-COVID Pulmonary Mucormycosis-A Case Report. Annals of Clinical and Medical Case Reports 2022