Fatal Disseminated Mucormycosis in an Immunocompotent Patient: A Case Report and Literature Review
A 64-year-old, previously healthy male was transferred to Alzahra Hospital (Isfahan University of Medical Sciences, Isfahan, Iran) in August 2011. 15 days before, he had a stroke following a cardiac surgery (mitral valve replacement and coronary artery bypass graft). The patient had no history of diabetes mellitus, alcohol abuse and malignancy. Upon admission physical examination revealed confusion, dysarthria, left side hemiparesis and extensive bedsores in the sacral area. Initial laboratory study showed leukocyte count: 15,000/mcl, hemoglobin: 10 mg/dl. During hospitalization, the neurological state of the patient gradually ameliorated; however, in the 7th day of admission, he developed dyspnea, productive cough and jaundice. Physical examination revealed fever, tachypnea, generalized jaundice and course crackles in the base of the left lung. New laboratory study showed leukocyte count 9700/mcl, hemoglobin 10 mg/dl, total bilirubin 6 mg/dl, (direct bilirubin 1 mg/dl), aspartate aminotransferase 154 U/L, alanine aminotransferase 122 U/L and alkaline phosphatase 1150 U/L. Human immunodeficiency virus antibody test was negative. Chest X-ray showed focal pneumonic infiltration in the left lower lobe. Abdominal ultrasonography showed no abnormality. Considering the probability of pneumonia, empirical antibiotic therapy was started. However, his condition deteriorated and without any response to the treatment he died within 24 h.\nIn the autopsy, multiple hemorrhagic foci on the pancreas and extensive perforations of spleen were two significant findings. Following the autopsy, each organ was separately put into 10% buffered formalin and abnormal macroscopic findings for each organ were recorded by the pathologist. Then, small slices with at least 0.5 cm were cut and the formalin solution was changed for the fixing overnight. The next day, proper cut for paraffin embedded tissue blocks were prepared. Two routine staining procedures including hematoxylin and eosin and periodic acid schiff were performed for tissue sections.\nHistopathological study of tissue sections revealed neutrophilic infiltration, massive coagulative necrosis and thrombotic vessels that some of them contained fungal hyphae in the left lung, pancreas, spleen and brain. On high power microscopic evaluation these hyphae appeared as ribbons which were often twisted and collapsed with a variable width. Septa in the most structures were absent. Some hyphae revealed swollen segments in cross-section [Figures –]. Hence, the histological findings were compatible with the diagnosis of mucormycosis. Despite making several cuts, no considerable finding was discovered in the other organs.