Justin Hanks, DO
Chief Medical Resident
Cleveland Clinic Main Campus
Cleveland, Ohio
Disclosure information not submitted.
Lin Chen, BA
Medical Student
Case Western School of Medicine, United States
Disclosure information not submitted.
Eduardo Mireles-Cabodevila, MD
Director , Medical Intensive Care Unit
Cleveland Clinic - Respiratory Institute
Cleveland, Ohio
Disclosure information not submitted.
Sudhir Krishnan, MD
Pulmonary and Critical Care Medicine Attending
Cleveland Clinic, Ohio, United States
Disclosure information not submitted.
Title: COVID-19 ASSOCIATED PULMONARY MUCOROMYCOSIS IN POST-PARTUM ECMO PATIENT TREATED WITH SALVAGE THERAPY
Case Report Body: Introduction: Mucormycosis carries significant mortality, overall upwards of 47%; pulmonary involvement rates can be as high as 87%. In the intensive care unit, patients requiring venovenous extracorporeal membrane oxygenation have similar mortality rates. Within this narrow cohort, the literature on mucormycosis is limited to a few case studies. While pulmonary mucormycosis has been well-described in the COVID-19 population, we report on a case of successful medical treatment of pulmonary mucormycosis in a post-partum patient on VV-ECMO for COVID-19 ARDS, which is the first to our knowledge.
Description: A 31-year-old female presented to a regional hospital at 27 weeks pregnant. She was found to have COVID-19 ARDS and underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was complicated by bilateral pneumothorax development and was refractory to proning requiring ECMO and transfer to a tertiary care center. At the tertiary center, chest radiography showed a new right lower lobe cavitating lesion with computed tomography (CT) scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with respiratory cultures later growing Lichtheimia spp. The patient underwent CT scan of the head and ENT evaluation which was negative for sino-nasal mucormycosis. Source control was discussed via possible open thoracostomy, but the patient was deemed a poor surgical candidate and medical management alone was continued. Persistent air leak in the chest tubes required transition to trach collar trial for bronchopleural fistula healing. Total ECMO support was 3 weeks, followed by de-cannulation and tracheostomy reversal. At the time of discharge to acute rehab, one month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant.
Discussion: Pulmonary mucormycosis, even in the non- ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.