PB2026 TRANSDIAPHRAGMATIC MUCORMYCOSIS
Authors: Köhler P. , Reimer R. , Schömig‐Markiefka B. , Cornely O. 
Published: June 2019

Background:Mucormycosis is a life‐threatening infection in immunocompromised patients and in haematological malignancy patients in particular.Aims:To report the phenomenon of transidaphragmatic mucormycosis and to raise concerns with regard to the extent of imaging studies in patients with mucormycosis.Methods:Retrospective chart review was performed on patients with Mucormycosis treated at the University Hospital of Cologne (UHC) between April 2012 and June 2017. Mucormycosis was confirmed either histologically or by culture. All cases were diagnosed pre‐mortem.Results:In a series of three patients we observed a previously unreported contiguous disease pattern, where the pulmonary type of disease contiguously spread through the diaphragm into abdominal organs, mostly liver or spleen.Patient 1, a 53‐year‐old women with history of B‐NHL, allogeneic stem cell transplantation and chronic renal disease developed mucormycosis of the lungs with continuous growth through the diaphragm into the liver. Fungal cultures and PCR of bronchoalveolar lavage and liver biopsy remained negative. Hepatic and diaphragm resection was performed and liposomal Amphotericin B (L‐AmB) >5 mg/kg once daily (QD) initiated. Histology showed invasive growth of fungal hyphae of the Mucorales order in liver and diaphragm. A planned lung resection was not possible due to progression of the disease and impossible one‐lung ventilation. The patient died seventeen days after the diagnosis was made.Patient 2, a 35‐year‐old man with history of acute myeloid leukemia and no further underlying conditions developed mucormycosis of the lungs with continuous growth through the diaphragm into the spleen. L‐AmB >5 mg/kg QD was initiated. Splenectomy was performed and histology showed invasive growth of fungal hyphae. Fungal cultures of the surgical sample remained negative, but panfungal PCR resulted in Rhizomucor spp. The patient died 976 days after the diagnosis was made, due to progression of the AML with neoplastic meningitis.Patient 3, a 42‐year‐old man with history of poorly controlled insulin‐dependent diabetes mellitus and injection drug use developed mucormycosis of the lungs with continuous growth through the diaphragm into the liver. Fungal culture of BAL fluid showed growth and PCR positivity of Rhizopus microsporus. Due to septic shock, high vasopressor support and extensive growth of mucormycosis, therapeutic goals were changed to palliative care. Therefore no surgery took place and no antifungal therapy was initiated. The patient died two days after the diagnosis was made.Summary/Conclusion:This is the first report of the clinical observation of transdiaphragmatic mucormycosis in 3 patients. We observed this phenomenon in 11% (3/27) of patients, raising concerns with regard to the extent of imaging studies in patients with mucormycosis. Clinicians should become aware of this new‐described entity. Upmost goal is to understand of the extent of the disease in order to personalize surgical debridement in combination with antifungal treatment. Therefore all patients with suspected mucormycosis should receive a complete staging with head, neck, chest and abdomen CT to find dissemination or contiguous rhinocerebral or transdiaphragmatic spread.