Mortierella wolfii–Associated Invasive Disease

a 34-year-old man was admitted because of severe shock to the intensive care unit (ICU) at University Hospital of Liege (Liege, Belgium) on day 10 after nonfamilial hematopoietic stem cell transplantation (HSCT). X-linked gp91phox gene mutation chronic granulomatous disease (CGD) had been diagnosed when he was 4 years of age. The patient had a history of recurrent pulmonary aspergillosis (Aspergillus fumigatus infection) and anaphylaxis to lipid-based formulations of amphotericin B (AmB). During the year before HSCT, he had received voriconazole for possible recurrent aspergillosis until 2 cavitary necrotic pulmonary lesions prompted prolonged combined treatment with caspofungin. No fungus was yielded before transplant. On day 9 after HSCT, a computed tomographic (CT) scan of the abdomen showed multiple hypodense lesions in the hepato-splenic paren-chyma, and the patient was admitted to the ICU. Antifungal drug administration were escalated (voriconazole 6 mg/kg twice daily, caspofungin 70 mg/day), taking into account patient's history of anaphylaxis. The patient recovered from aplasia within 12 days (1), and CT-guided liver biopsy was performed on day 20 after HSCT. Microbiological cultures of the liver biopsy sample were performed on 5% sheep blood agar and Sab-ouraud agar medium supplemented with chloramphenicol. The plates were incubated at 30°C and 37°C, respectively, for 10 days. Subcul-tures were performed on malt agar, Takashio, and agar-agar medium and incubated at 30°C, 37°C, and 42°C, respectively, to obtain sporulation. Blood cultures were collected on the same day the biopsy was performed on BacT/ALERT FAN aerobic and anaerobic medium bottles (bioMéri-eux, Durham, NC, USA). Antifungal susceptibility testing was performed by Etest. Histopathologic examination was conducted after the liver sections were stained with hematoxylin and eo-sin, periodic acid–Schiff, and Gomori methenamine silver. We sequenced regions of internal transcribed spacers (ITS) 1 and 2 of the rRNA genes (2).The ribosomal target of the large subunit RNA gene (D1–D2 region) was used to confirm the first results. Sequences were aligned by using the GeneStudio Pro software Histologic examination of the liver biopsy sample showed fungal filaments of variable diameter, without septa, and with bulbous dilations suggesting mucormycosis amid necrotic parenchyma (Figure). A white fila-mentous mold grew after the sample was incubated for 2 days on Sabouraud agar at 30°C and 5% sheep blood agar medium at 37°C. Microscopic examination of the culture confirmed a fungus belonging to the mucoromycotina. Nonseptate hyphae of irregular width were visible and marked by short lateral extensions distributed at right angles along the …