A 19-year-old man with progressive lung infiltrates

TREATMENT WITH AMPHOTERICIN

The treatment includes giving effective antifungal agents promptly, correcting hyperglycemia and metabolic acidosis, reversing immunosuppression (if possible), and considering surgical debridement.^1,2

Antifungal therapy is with conventional amphotericin B (Amphocin) or its lipid formulation (Abelcet). The lipid formulation is at least as effective as conventional amphotericin B and less nephrotoxic, thus allowing higher doses.^1,9 The optimal duration of therapy has not been evaluated, but experts in general treat until the pulmonary and sinus lesions have resolved.²

Posaconazole (Noxafil), a broad-spectrum oral azole, has activity in vitro and is a valuable alternative for patients who have refractory zygomycosis or who cannot tolerate amphotericin B.^5,10

The role of echinocandins is unclear, as they do not have in vitro activity against Zygomycetes. However, tests in animals have shown a synergistic effect between the echinocandin caspofungin (Cancidas) and amphotericin B lipid complex.¹¹ Other antifungal agents such as azoles lack activity against Zygomycetes.⁵

The return of neutrophils plays a substantial role in resolving the infection in neutropenic patients, a proposition supported by reports of the failure of antifungal therapy in patients with persistent neutropenia.¹ The addition of granulocyte colony-stimulating factor may accelerate neutrophil recovery and enhance neutrophil activity against opportunistic fungal pathogens.¹²

Even though progress has been made in the treatment of this disease, the prognosis continues to be poor in patients with hematologic malignancies and pulmonary or disseminated zygomycosis.⁹

ENDOBRONCHIAL ZYGOMYCOSIS

Aspergillosis is the most common endobronchial fungal disease. Zygomycosis is the third most common, after coccidioidomycosis. In zygomycosis, endobronchial lesions can be found in a third of patients who have pulmonary involvement.^6,13,14

The most common predisposing conditions for the development of endobronchial zygomycosis are diabetes and hematologic malignancies associated with neutropenia.¹⁴

Endobronchial zygomycosis is characterized by a locally invasive gray-white mucoid lesion that blocks a major airway.¹³ The involved airway is usually edematous and necrotic. The diagnosis can be made by visualizing the organism in bronchial washings, brushings, or endobronchial biopsies.¹⁴

If the disease is not promptly diagnosed, the risk of death is very high. The management includes high-dose conventional or lipid amphotericin B and surgical or endobronchial resection.^13,15

OUR CASE CONTINUED

After Zygomycetes was seen in the tissue from his bronchial biopsy, our patient received amphotericin B lipid complex at 5 mg/kg/day (started between images C and D in Figure 1). He had a good initial clinical response, but the infection progressed (image D in Figure 1).

The patient died as a result of massive hemoptysis attributable to the angioinvasive nature of the fungus, which most likely caused an erosion of a major pulmonary vessel.

TAKE-HOME POINTS

• Pulmonary disease is the most common manifestation of zygomycosis in patients with underlying hematologic malignancy. In this setting, zygomycosis has a high rate of morbidity and death.
• Endobronchial lesions can be seen in up to a third of patients with pulmonary zygomycosis.
• Prompt and effective therapy is essential for treatment to be successful.