A 65-year-old female with multiple comorbidities (poorly controlled diabetes mellitus, cardiac arrhythmia, hypertension, chronic kidney disease, and remote diagnosis of intraductal papillary mucinous neoplasm of the pancreas status post-Whipple’s resection) presented with 5 days history of nonproductive cough, fever, shortness of breath, right chest pain, and headache after failing a course of oral amoxicillin. On admission, she was febrile and hypoxic with an oxygen saturation of 92% at room air. Physical examination was unremarkable. There is no significant exposure besides gardening. Laboratory studies showed a white blood cell count of 20,000/ll (normal, 4000–10,000/ll) with neutrophils 83.6% (normal, 42–66%) and 8.7% lymphocytes (normal, 20–40%), a creatinine of 4.53 mg/dl (normal, 0.6–1.2 mg/dl) with blood urea nitrogen 66 mg/ml (normal, 7–20 mg/ml). Glucose level was 132 mg/dl (normal, 70–99 mg/dl) and hemoglobin A1c was 9.6% (normal, B 5.6%). A chest X-ray showed right upper lobe infiltrates for which cefepime 1 g IV Q12 h and vancomycin 15 mg/kg Q12 h were initiated. However, patient remained febrile despite antibacterial therapy and progressed to respiratory failure that required mechanical ventilation on day 5 of hospital admission. A chest CT scan (Fig. 1a) revealed an extensive right upper lobe infiltrating with a dense rind of opacity was noted. On day 7 postadmission, she developed seizures and left hemiparesis with CT scan of the brain without contrast (Fig. 1c) showed subfalcine herniation, midline shift and a hypointense mass in the right frontal lobe with vasogenic edema concerning for a primary glial tumor, with normal sinuses. Intravenous dexamethasone (4 mg every 8 h) was started and a bronchoalveolar lavage culture yielded Rhizopus species. Liposomal amphotericin B (LAMB) 7.5 mg/kg daily was introduced (Day 11 post-admission). A CT abdomen and pelvis exhibited hepatic, renal, and splenic infarctions. No valvular vegetations were seen on transesophageal echocardiography. The subsequent hospital course was torpid, complicated with worsening cerebral edema requiring emergent craniotomy with frontal lobectomy. Brain necrosis with thrombosed vessels was identified and histopathology studies revealed acute necrotizing cerebritis and abscess formation. Hematoxylin and eosin plus Grocott-Gomori methenamine silver stains showed broad, non-septate hyphae consistent with mucormycosis (Fig. 1b and d). Culture from the brain specimen yielded Rhizopus species. Given her poor prognosis, patient was placed on comfort care and expired. Mucormycosis is an emerging invasive fungal infection and risk factors include poorly controlled diabetes mellitus, hematologic malignancies, solid organ and stem cell transplantation, and iron overload (especially those receiving deferoxamine). As in our case, disseminated mucormycosis is defined as an

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一例模拟恶性肿瘤的播散性毛霉菌病致死病例

一名 65 岁女性，患有多种合并症（糖尿病控制不佳、心律失常、高血压、慢性肾病，以及远程诊断惠普尔切除术后胰腺导管内乳头状黏液性肿瘤）5 天的干咳史口服阿莫西林失败后发烧、呼吸急促、右胸痛和头痛。入院时，她发热、缺氧，室内空气氧饱和度为 92%。体格检查无异常。除了园艺，没有显着的暴露。实验室研究显示白细胞计数为 20,000/ll（正常，4000-10,000/ll），中性粒细胞为 83.6%（正常，42-66%），淋巴细胞为 8.7%（正常，20-40%），肌酐为 4.53 mg/dl（正常，0.6–1.2 mg/dl），血尿素氮 66 mg/ml（正常，7–20 毫克/毫升）。葡萄糖水平为 132 mg/dl（正常，70-99 mg/dl），血红蛋白 A1c 为 9.6%（正常，B 5.6%）。胸部 X 光片显示右上叶浸润，为此开始使用头孢吡肟 1 g IV Q12 h 和万古霉素 15 mg/kg Q12 h。然而，尽管进行了抗菌治疗，患者仍然发热，并在入院第 5 天发展为需要机械通气的呼吸衰竭。胸部 CT 扫描（图 1a）显示广泛的右上叶浸润，可见致密的不透明皮。入院后第 7 天，她出现癫痫发作和左侧偏瘫，脑部 CT 扫描无对比（图 1c）显示镰刀下疝、中线移位和右额叶低信号肿块，伴有血管源性水肿，与原发性神经胶质瘤有关，伴有正常的鼻窦。开始静脉注射地塞米松（每 8 小时 4 毫克），支气管肺泡灌洗培养产生根霉属物种。引入脂质体两性霉素 B (LAMB) 7.5 mg/kg 每天（入院后第 11 天）。CT 腹部和骨盆显示肝、肾和脾梗塞。经食管超声心动图未见瓣膜赘生物。随后的住院过程是麻木的，并发脑水肿恶化，需要紧急开颅手术和额叶切除术。确定了血管血栓形成的脑坏死，组织病理学研究显示急性坏死性脑炎和脓肿形成。苏木精和伊红加 Grocott-Gomori methenamine 银染色显示与毛霉菌病一致的宽阔无隔菌丝（图 1b 和 d）。来自大脑标本的培养产生了根霉属物种。鉴于她的预后不佳，患者接受了舒适护理并死亡。毛霉菌病是一种新出现的侵袭性真菌感染，其危险因素包括控制不佳的糖尿病、血液系统恶性肿瘤、实体器官和干细胞移植以及铁过载（尤其是那些接受去铁胺治疗的患者）。在我们的案例中，播散性毛霉菌病被定义为