case_images: PMC11233786_01
case_images: Enhanced chest computed tomography (CT) and enhanced abdominal CT at admission captured layers with lesions, although not all lesions are depicted. (A) Mass in the right middle lobe with bronchus occlusion, atelectasis, and a nodule in the lower right lobe, previously punctured. (B) New lower right lobe nodule compared to her first chest CT from the previous hospital. (C) Right-sided pleural effusion and a new lesion in the left upper lobe. (D) Interruption of the right upper pulmonary vein by the right middle lobe. (E) Invasion of the left atrium and mural thrombosis by the right middle lobe mass. (F) Nodule in the right chest wall. (G) Double nodules in the spleen. (H) Wedge-shaped nodules in her kidneys and a nodule in the pancreas.
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case_images: F1
case_images: Additional nodules were found in the lower right lobe, and the right middle lobe mass invaded her right pulmonary veins and left atrium on enhanced chest CT at 1 month (Figures 1A-E). Enhanced chest and abdominal CT revealed multiple nodules in her right chest wall, kidneys, spleen, and pancreas (Figures 1F-H).
case_images: Enhanced brain magnetic resonance imaging (MRI) of the patient taken at admission (A-C) and Day 65 (D-F), showing some but not all lesions. (A, D) Lesion in the right cerebellar hemispheres, larger on Day 65 than at admission, with wider brain edema and a left-shifted midline with the fourth ventricle more compressed. (B, E) Lesion in the right frontal lobe, smaller on Day 65 than at admission. (C, F) Double lesions of the occipital lobe, larger on Day 65 than at admission.
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case_images: F2
case_images: Brain-enhanced magnetic resonance imaging (MRI) at admission showed ring-enhancing lesions in the right cerebellar hemisphere, right frontal lobe, and bilateral occipital cutaneous medullary junction, as well as abnormal signals in the right frontal lobe with meningeal enhancement (Figures 2A-C). A brain-enhanced MRI (Figures 2D-F) revealed a reduced frontal lobe but increased size in other areas with severe edema.
case_images: Histopathology and microbiology findings from both biopsy specimens. (A) Wide, non-septate hyphae in the Gram staining of the left forearm nodule specimen. (B) Wide, non-septate hyphae in the fungal fluorescence of the left forearm nodule specimen. (C) Cultured subcutaneous nodule was cultured on potato glucose agar showing Rhizopus microspora growth at 35 C for four days, with a moderately floccose mycelium colony. (D) Lactophenol cotton blue staining of the isolated strain, and its globose small sporangium (arrows) is dissolving and releasing oval or irregular sporangiospore (arrowheads). (E, F) Hematoxylin and eosin (H&E) staining of the right lower lung puncture specimen, (E) indicates chronic collagen fibrous hyperplasia, and (F) indicates a huge amount of eosinophilic infiltration. (G) Wide, non-septate hyphae resembling those in subcutaneous tissue with periodic-acid silver methenamine staining of the specimen from the right lower lung puncture. (H) Wide, non-septate hyphae resembling those in subcutaneous tissue with fungal fluorescence of the specimen of the right lower lung puncture.
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case_images: F3
case_images: Wide, non-septate hyphae were found using Gram staining (Figure 3A) and fungal fluorescence (Figure 3B) of the left forearm nodule specimen. Furthermore, lung puncture specimen analysis revealed wide, non-septate hyphae with chronic collagen fibrous hyperplasia, accompanied by a significant presence of eosinophilic infiltration and a few multinuclear giant cell reactions, indicating invasive pulmonary mucormycosis overlapping with lung tissue allergic reaction (Figures 3E-H).
case_images: Treatment course. Liposomal amphotericin B (10 mg/kg, QD) administered intravenously from Day 1 to Day 6, followed by isavuconazole (200 mg Q8H for the first 48 h intravenously, then 200 mg QD orally) from Day 7. Simultaneously, methylprednisolone was administrated with 40 mg/day (body weight of 53 kg, prednisone equivalent of 1 mg/kg) from Day 1, reduced to 32 mg/day from Day 8, and gradually tapered. The patient's peak body temperature declined on Day 2 and returned to normal on Day 4. She suffered from gastric perforation on Day 20, leading to the discontinuation of methylprednisolone. Reduction in pulmonary lesions and decreased eosinophils were observed. Hemoptysis, multiple pulmonary embolisms, and intracranial hypertension occurred on Days 62-65, resulting in the patient's death. WBC, white blood cells; EOS, Eosinophils; QD, once daily; Q8H, every 8 h.
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case_images: F4
case_images: The treatment course (Figure 4) was divided into two phases due to the complication of gastric perforation.