final program.qxd - Parallels Plesk Panel

PP 6.19
Multiple sclerosis managed without immunosuppressive therapy.
Detection of pulmonary zigomycosis as an indolent fungal complication
Roberto Manfredi, Leonardo Calza
Infectious Diseases, University of Bologna, Italy
Introduction
Mucormycosis (M) is a infrequent filamentous fungal infection borne by a very elevated
fatality rate despite prompt diagnosis and adequate therapy, especially in its frequent
rhinocerebral presentation, and/or when decompensated diabetes mellitus, neutropenia,
or immunosuppression are of concern.
Case Report
A 53-year-old female patient (p) with a multiple sclerosis previously treated with steroidsazathioprine
(but controlled since three months without any treatment), was hospitalized
owing to cough and hemophtoe, in absence of dyspnea, other respiratory symptoms, and
fever. Laboratory testing did not disclose significant abnormalities (total leukocyte count
and differential, ESR, and serum glucose were within noraml limits), and tumoral markers
tested negative, but the detection of multiple lung infiltrates at chest X-ray and HRCT
(predominant at right lobes, with an appreciable air bronchogram), prompted a
bronchoscopy with biopsy and bronchoalveolar lavage involving the medial right lobar
bronchus area. After an uncertain microscopy (with Aspergillus hyphae still suspected),
and negative serum Aspergillus antigen search, cultures led to the isolation of Mucor spp.,
with tested in vitro susceptible to amphotericin B and posaconazole, while it was resistant
to itraconazole and voriconazole. Liposomal amphotericin B (at 3 mg/Kg/day) was
delivered for six weeks predominantly on Day-Hospital basis with favorable tolerability: no
hematological, blood chemistry and urinalysis alterations occurred. One month later, our
p completely recovered, and a repeated HRCT and bronchoscopy confirmed a complete
clinical, radiological, and mycological cure.
Discussion
M is a rare occurrence, especially when neutropenia and ketoacidosis are absent.
However, anecdotal reports occurred after trauma, and during COPD. Although the usual
portal of entry of M is respiratory, however the rhinocerebral M remains the most frequent
and life-threatening presentation. Clinicians should consider M even when obvious risk
factors and an apparently slow progression are found. The diagnostic procedures includes
microscopic differentiation from Aspergilli, although mixed infections are not so rare. In
pulmonary forms, percutaneous biopsy becomes sometimes needed. Liposomal
amphotericin B remains the treatment of choice, but surgery is sometimes necessary, in
order to debride extensive necrotic areas due to angioinvasion; some doubt remains
about the role of hperbaric O2 therapy. In our p, a slowly progressive pulmonary M was
identified and cured in a reasonably short time, even in absence of underlying, active risk
factors, and a rapidly overwhelming clinical progression.
“ Focusing FIRST on PEOPLE “ 236 w w w . i s h e i d . c o m