A 40-year-old male with a past medical history of poorly controlled type 1 diabetes mellitus (HbA1c 10.3%) presented to the emergency department with a one-week history of fever, chills, shortness of breath, and hemoptysis. On admission, the patient was febrile (101  F) and tachycardic (110 beats/min). He required 3 L of supplemental oxygen via nasal cannula to maintain oxygen saturation above 94%. The pulmonary exam was unrevealing. Laboratory workup was unrevealing, including a normal white blood cell count and procalcitonin. Chest X-ray was grossly unremarkable (Fig. 1). Computed Tomography (CT) of the chest showed a cavitary mass (3.5 x 2.9 cm) in the right lower lobe (Fig. 2). He was started on vancomycin and piperacillin/tazobactam after collecting sputum and blood cultures. Sputum was also sent for acid-fast bacillus (AFB) smear and culture. Throughout the course of hospitalization, these cultures remained negative.
Despite antibiotherapy, the patient's symptoms continued to worsen. A flexible bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) under general anesthesia was performed on day 7 of hospitalization. Bronchoscopy revealed a yellow-colored, friable, slimy, endobronchial mass occluding the right lower lobe bronchus (Fig. 3). Mediastinal and hilar lymph nodes were sampled, with rapid on-site cytology negative for malignancy. Endobronchial biopsies with cryoprobe were performed. Extraction of the lesion was attempted first with the cryoprobe, then by gastrointestinal biopsy forceps, and lastly with a polypectomy snare. However, the attempts were unsuccessful as the mass was very elastic, with the stem firmly attached to the right lower lobe parenchyma. Forceps biopsies and cytology brushing of the mass were also performed. Histopathological examination of the specimen from the mass was consistent with pulmonary mucormycosis, with broad, non-septate hyphae, characteristic of Mucorales species (Fig. 4). No malignant cells or fungal elements were seen on cytological examination of lymph nodes' aspirates, and the cultures were negative. The patient was started on Amphotericin B at 5 mg/kg daily on hospital day#11. Thoracic surgery was consulted, and right middle and lower lobes lobectomy was completed on hospital day#15 without any complication. The removed specimen is shown in Fig. 5. He finished a 14-day course of intravenous Amphotericin B with clinical improvement. He was transitioned to oral Posaconazole and discharged on hospital day#26. At the 3-month follow-up, he reported complete resolution of symptoms.
Chest CT demonstrating a right lower lobe cavitating mass (3.5 x 2.9 cm).