immunocompromised patients might bear a variety of presentations such as rhino - orbito - cerebral , pulmonary , gastrointestinal , cutaneous , central nervous system and disseminated form . rhino - orbito - cerebral and pulmonary mucormycosis are the most common forms ; the latter progresses rapidly to devastating diseases . presentation of pulmonary mucormycosis may be confused with several infectious and non infectious diseases ; therefore its diagnosis is difficult . chest ct scan of a patient with pulmonary mucormycosis might demonstrate such presentations as air crescent sign , ct halo sign , solitary or multiple pulmonary nodules or masses , bronchopulmonary fistula and pulmonary artery pseudo aneurysm . the occurrence of pneumothorax and its subsequent rhs along with sinusitis , supported by radiology and pathology in a 33 years old patient , is considered as a rare case of pulmonary mucormycosis . following is the treatment history of a man , 33 years old in july 2014 ( day + 14 ) , when he died in our hospital as a result of multiorgan failure . he was a farmer , married , with no history of alcohol consumption , illicit drugs use and extramarital relationships . on day 330 : because of edema he visited a medical center in another city , where he was admitted and membranous glomerulonephritis was diagnosed . consequently the followings administered ; prednisolone and cyclosporine for 2 months , cellcept for 1 month , prednisolone and cyclophosphomide for 7 months . on day 75 : because of progressive generalized edema he was admitted again . he was discharged under treatment with prednisolone ( 50  mg / daily ) and tacrolymus ( 1 cap / bd ) . during the next 2 months he was feeling fine . on day 28 , he travelled to village for a few days and he had close contact with sheep . on day 14 the patient reported fever , cough and dyspnea with mild erythema and pain in right eye . anorexia , weakness , dyspnea and conjunctivitis developed and persisted despite of outpatient antibiotic treatment . in the emergency department ( day 0 ) : the patient suffered from dyspnea , weakness and right eye pain . on examination , he was agitated but completely conscious with diaphoretic skin . the vital signs have been as follows ; temperature , 36.7  c ; blood pressure , 100/60  mmgh ; pulse rate , 99 beats per minute ; respiratory rate , 22 beats per minute and oxygen saturation in air room , 99% . in right eye , there was moderate conjunctivitis with eyelid erythema ; its movement was normal . the first day chest ct scan revealed large pleural effusion with pneumothorax in the left side and a shift of mediastinum to the right side . 1 ) . consequently drainage with chest tube was administered by the surgeon immediately . because of the immunocompromised state of the patient , parenteral trimethoprim- sulfamethaxazol ( 160  mg / iv / tds ) and meropenem ( 1  g / iv / bd ) were administered for pneumocystis jiroveci and multi drug resistant organisms . we also started fluconazole for oral lesions . on day + 3 , right eye erythema was extended with small size necrosis in right nasal ala without bleeding ( fig . with doubt of rhino - orbital mucormycosis , biopsies of tongue and nasal septa were carried out and amphotericin b deoxycholate ( 1  mg / kg / daily ) was administered . on day + 4 , paranasal sinuses ( pns ) ct scan revealed soft tissue density lesion in left ethmoid sinus and nasal passage with extension to left orbit ( fig . , he was transferred to intensive care unit ( icu ) because of respiratory distress and was intubated after 48  h ; his conscious level was 14+t/15 . smear of sputum for acid fast bacilli , stain and culture of sputum for pneumocystis jiroveci were negative . hiv antibody test , d - dimer enzyme -linked immunosorbent assay ( elisa ) and collagen vascular diseases screening tests were negative ( table 1 ) . pleural fluid cytologic examination and polymerase chain reaction ( pcr ) for fungi were negative . on day + 6 , laboratory results revealed pancytopenia ( table 1 ) , however in peripheral blood smear there was no schistocyte or immature cells . bone marrow biopsy which could help in finding the cause of pancytopenia was nevertheless postponed due to the patient 's poor condition and low platelet count . meanwhile his blood pressure was decreased and we started inotropic drugs.hemodynamic instability of the patient prohibited further attempts such as bronchoscopy and ct guided lung biopsy to identify the causative agent . on day + 9 , section of tounge biopsy showed ulcerated squamous epithelial mucosa with subepithelial fibro fatty tissue and skeletal muscle fibers of tongue that is on site of ulceration . the inflammatory granulation tissue and inflammatory multinucleated giant cells were also seen in gimsa staining , but no cyst and trophozoite of pneumocystis jiroveci were identified . pulmonary mucormycosis is a devastating infection when it affects immunocompromised patients such as diabetes mellitus , hematologic malignancies , chronic renal failure , post transplantaion and immunosuppressed persons . herein , we present a rhino - orbital mucormycosis with pulmonary involvement . reticulation inside the rhs , presence of pleural effusion , multiple nodules and concomitant rhino - orbital mucormycosis as well as documented pathology , collectively were considered as indicating that pulmonary involvement has been due to mucormycosis . the pathological finding is achieved by tongue tissue ; lung biopsy has not been possible due to poor condition of the patient . our case was an immunocompromised patient with documented rhino - orbital mucormycosis ( figs . 3 , 5 and 6 ) . chest ct scan showed bilateral pleural effusion , multiple nodules and rhs with thin reticulation ( figs . 1 and 4 ) . although histopathology findings are usually needed to establish the diagnosis of pulmonary mucormycosis , using ct imaging and clinical presentation we can avoid the invasive procedures such as lung biopsy . there are few case reports of pneumothorax in pulmonary mucormycosis , some of which are iatrogenic during mechanical ventilation and bronchoscopic procedure [ 911 ] . combined mucormycosis and methicillin - resistant staphylococcus aureus ( mrsa ) were found to be responsible for life threatening pneumothorax in an immunocompromised patient . mucormycosis and aspergillus have been recognized as leading to pneumonia and pneunothorax in a dialysis patient . however , spontaneous pneumothorax in pulmonary mucormycosis that is followed by rhs seems to be a unique case . based on patient 's background and clinical signs , amphotericin b deoxycholate ( 1  mg the lower dose of antifungal drug has been due to the patient 's renal insufficiency . ambisome would have certainly been a better choice than amphotericin b ; however , the former has not been available in iran . however the lack of bone erosion in sinus ct scan , delay in pathologic result and patient 's poor clinical condition , lead into the reluctance of surgeon for extensive debridement that had negative impact on patient 's prognosis . pneumothorax which is due to mucormycosis can be fatal particularly in immunocompromised persons , so clinicians should take immediate measures ( follow up imaging and pathology ) to confirm or reject the presence of invasive fungal infection . if confirmed , antifungal therapy is necessary as soon as possible .
mucormycosis , an invasive fungus with a variety of clinical presentation , is a devastating infection in immunocompromised host . here 
 an unusual case of pulmonary mucormycosis is introduced in an immunodeficient patient in which pneumothorax was followed by reversed halo sign ( rhs ) . 
 the clinicians , who visit immunocompromised persons with pneumothorax , should be considerate to take immediate imaging and pathologic measures to confirm or reject mucormycosis .