Pulmonary zygomycosis in a diabetic patient: treated with pneumonectomy and antifungal agents.

A 47-year-old woman with diabetes type II, asthma, managed with albuterol and inhaled steroids, and a history of laparoscopic gastric bypass six years ago, presented to her primary care provider with cough and gray-colored sputum for one week, and was initiated on azithromycin and prednisone. One week later she presented to the Emergency Department with progressive cough, shortness of breath, thirst, increased urinary frequency, and altered mental status. She was found to be in a hyperglycemic, hyperosmolar state. A chest radiograph showed left upper-lobe opacity and computed tomography of her chest revealed a large left upper-lobe cavitary lesion. Sputum cultures were positive for Rhizopus species. Treatment with AmBisome was initiated and the patient underwent left-sided pneumonectomy. Pathological evaluation of the lobe revealed a 7.5 x 6.8 x 3.3 cm sharply demarcated necrotic cavity involving the majority of the left upper lobe with little surrounding uninvolved lung parenchyma (Figure 1). The cavity was surrounded by an erythematous rim, and within contained discohesive black-brown necrotic debris. Microscopic examination was significant for necrosis and acute inflammation, both surrounding and within the cavitation. Innumerable broad hyphae with rare septations were identified. The hyphae were irregularly branched at 90-degree angles, consistent with Rhizopus sp. (Figure 2). A Periodic acid-Schiff stain confirmed the presence of these organisms. The patient tolerated pneumonectomy well, and her clinical condition improved. Eventually she was discharged and scheduled for routine follow-up.