Scientific Letter
Mucormycotic Pulmonary Pseudoaneurysm Causing Fatal Hemoptysis
Hemoptisis letal causada por un pseudoaneurisma pulmonar mucomircótica
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Coronal computed tomography image (B) obtained with the lung window setting demonstrating the thick-walled cavitary lesions, with solid content in one lesion on the right. Axial contrast-enhanced image (C) obtained with the mediastinal window setting depicting the solid content in the lower cavity, with a highly enhancing nodule inside (arrow), compatible with an aneurysm. Computed tomography–pulmonary angiography image (D) demonstrating that the pseudoaneurysm is related to a peripheral pulmonary artery (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luciana Volpon Soares Souza, Arthur Soares Souza, Edson Marchiori" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Luciana Volpon Soares" "apellidos" => "Souza" ] 1 => array:2 [ "nombre" => "Arthur Soares" "apellidos" => "Souza" ] 2 => array:2 [ "nombre" => "Edson" "apellidos" => "Marchiori" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212919303039" "doi" => "10.1016/j.arbr.2019.03.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212919303039?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289619302170?idApp=UINPBA00003Z" "url" => "/03002896/0000005500000011/v4_202003140718/S0300289619302170/v4_202003140718/en/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1579212919303003" "issn" => "15792129" "doi" => "10.1016/j.arbr.2019.04.012" "estado" => "S300" "fechaPublicacion" => "2019-11-01" "aid" => "2144" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2019;55:600" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Cerebral Air Embolism After CT-guided Lung Biopsy: A Case of Early Diagnosis and Successful Treatment" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "600" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embolismo aéreo cerebral tras una biopsia pulmonar guiada por CT: un caso de diagnóstico temprano y tratamiento exitoso" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1663 "Ancho" => 1733 "Tamanyo" => 206486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest CT prior biopsy. The white arrow indicates the target lesion in the right upper lobe, in close proximity to the main fissure. (B) Chest CT during the biopsy. An 18-gauge Tru-Cut needle is successfully advanced through the target nodule under continuous CT-fluoroscopy guidance, as indicated by the white arrow. (C) Brain CT 19<span class="elsevierStyleHsp" style=""></span>min after the biopsy. The white arrows indicate air in the right superior frontal, precentral, central (A) and superior temporal (B) sulci, consistent with cerebral venous air embolism. (D) Brain CT 3 days after biopsy showing complete resorption of the air bubbles. 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Coronal computed tomography image (B) obtained with the lung window setting demonstrating the thick-walled cavitary lesions, with solid content in one lesion on the right. Axial contrast-enhanced image (C) obtained with the mediastinal window setting depicting the solid content in the lower cavity, with a highly enhancing nodule inside (arrow), compatible with an aneurysm. Computed tomography–pulmonary angiography image (D) demonstrating that the pseudoaneurysm is related to a peripheral pulmonary artery (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 40-year-old diabetic man with 40 pack-years smoking exposure presented to the emergency department with a 30-day history of fever, dyspnea, and productive cough with thick yellowish sputum, later associated with hemoptysis. The patient had type 2 diabetes mellitus and reported unmeasured weight loss over the last month. Laboratory tests revealed leukocytosis (18,500<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>); the patient's blood glucose level was 296<span class="elsevierStyleHsp" style=""></span>mg/dL and his glycosylated hemoglobin concentration was 12.8%. His basal oxygen saturation was 89%. Other laboratory findings were unremarkable. A chest-X ray showed three cavitary lesions with air-fluid levels (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The patient's sputum was negative for acid-fast bacilli.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Contrast-enhanced chest computed tomography (CT) disclosed thick-walled cavitary lesions, one with solid content and a pseudoaneurysm inside, located on a peripheral ramification of the right pulmonary artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B–D). Fiberoptic bronchoscopy revealed necrotic material covering the right main bronchial mucosa. Bronchoalveolar lavage (BAL) demonstrated the presence of fungal hyphae suggestive of zygomycosis. Cultures confirmed the presence of <span class="elsevierStyleItalic">Rhizopus</span> species. The patient was treated with amphotericin B. During hospitalization, he had several episodes of hemoptysis, and he died of massive hemoptysis on the second day after the internation admission.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Mucormycosis (also known as zygomycosis) is a fulminant opportunistic fungal infection caused by fungi of the order Mucorales, class Zygomycetes. Mucormycosis is far less common than other opportunistic fungal infections, such as <span class="elsevierStyleItalic">Aspergillus</span> and <span class="elsevierStyleItalic">Candida</span> infections, although the mortality rate is much higher. Although Classically described in patients with diabetes (especially diabetic ketoacidosis), in the modern era it is seen most commonly in patients with hematological malignancies, particularly those who have undergone stem cell transplantation.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> Lin et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> described 35 patients with confirmed pulmonary mucormycosis; hematological malignances were found in 68% and diabetes in 20% of the cases.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Mucormycosis manifests in the sinuses (39%), lung (24%), skin (19%), brain (9%), and gastrointestinal tract (7%), and as disseminated disease (6%). The respiratory symptoms of pulmonary mucormycosis are diverse, including fever, cough, expectoration, chest pain, and breathing difficulties.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> Mucorales species are angioinvasive, which leads to vessel rupture with massive hemorrhage and infarction of the distal tissue. Hemoptysis is a common complication and can be massive, causing sudden death.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The clinical diagnosis of mucormycosis is difficult, and is often made at a late stage or postmortem. The diagnosis relies on the identification of organisms in tissues by pathological examination, with confirmation by culture.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2,5</span></a> However, some authors have reported, as in our case, initial diagnosis by identification of the fungus in sputum or BAL fluid, with subsequent confirmation by culture. In one case series, 25% of sputum or BAL specimens allowed positive identification.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The main differential diagnosis is pulmonary aspergillosis. On pathological examination, hyphae characteristics differ between <span class="elsevierStyleItalic">Mucor</span> and <span class="elsevierStyleItalic">Aspergillus</span> species. The hyphae of <span class="elsevierStyleItalic">Mucor</span> species are thick and non-septate, and have larger diameters than the hyphae of <span class="elsevierStyleItalic">Aspergillus</span> (which have fewer, irregular branches and form right or obtuse angles).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Most patients with pulmonary mucormycosis show consistent sequential morphological changes on serial follow-up imaging, consisting initially of consolidation or nodules/masses with the CT halo sign, followed by the reversed halo sign or central necrosis and, finally, the air-crescent sign. These changes are related to recovery of the absolute neutrophil count.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a>Aneurysms affecting the pulmonary arteries are extremely uncommon. The most common cause of this complication is infection. Other causes are pulmonary hypertension, pulmonary arteritis, cystic medial necrosis, and thoracic trauma. The most common organisms are bacteria. Fungal invasion of pulmonary artery walls, resulting in pseudoaneurysm formation, is exceedingly rare.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,7,8</span></a> Physicians should consider pulmonary mucormycosis in immunocompromised patients with unresolved pneumonia. In addition, the high fatality rates associated with pulmonary artery pseudoaneurysm warrant aggressive management with surgery and antifungal agents.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1313 "Ancho" => 1500 "Tamanyo" => 252628 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Posteroanterior chest radiograph (A) showing three large cavitary lesions, two on the right lung and one on the left, with air-fluid levels. Coronal computed tomography image (B) obtained with the lung window setting demonstrating the thick-walled cavitary lesions, with solid content in one lesion on the right. Axial contrast-enhanced image (C) obtained with the mediastinal window setting depicting the solid content in the lower cavity, with a highly enhancing nodule inside (arrow), compatible with an aneurysm. Computed tomography–pulmonary angiography image (D) demonstrating that the pseudoaneurysm is related to a peripheral pulmonary artery (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive pulmonary mucormycosis with concomitant lung cancer presented with massive hemoptysis by huge pseudoaneurysm of pulmonary artery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.I. Kim" 1 => "H.C. Kang" 2 => "H.S. Lee" 3 => "J.S. Choi" 4 => "K.H. Seo" 5 => "Y.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 34 | 16 | 50 |
| 2024 September | 38 | 11 | 49 |
| 2024 August | 40 | 32 | 72 |
| 2024 July | 34 | 18 | 52 |
| 2024 June | 36 | 20 | 56 |
| 2024 May | 50 | 25 | 75 |
| 2024 April | 23 | 29 | 52 |
| 2024 March | 30 | 21 | 51 |
| 2024 February | 24 | 18 | 42 |
| 2024 January | 1 | 0 | 1 |
| 2023 March | 7 | 2 | 9 |
| 2023 February | 24 | 22 | 46 |
| 2023 January | 17 | 31 | 48 |
| 2022 December | 38 | 32 | 70 |
| 2022 November | 34 | 20 | 54 |
| 2022 October | 44 | 37 | 81 |
| 2022 September | 21 | 23 | 44 |
| 2022 August | 26 | 36 | 62 |
| 2022 July | 22 | 33 | 55 |
| 2022 June | 25 | 37 | 62 |
| 2022 May | 25 | 23 | 48 |
| 2022 April | 27 | 25 | 52 |
| 2022 March | 27 | 34 | 61 |
| 2022 February | 20 | 31 | 51 |
| 2022 January | 32 | 35 | 67 |
| 2021 December | 31 | 38 | 69 |
| 2021 November | 29 | 37 | 66 |
| 2020 April | 1 | 0 | 1 |
| 2020 March | 2 | 0 | 2 |
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