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Case report of pulmonary mucormycosis in pregnancy
Abstract Number: S5C-5
Abstract Type: Case Report/Case Series
Mucormycosis is a rare but serious life-threatening fungal infection that occurs in immunosuppressed patients. Treatment is challenging, requiring long-term antimicrobial therapy and surgical debridement of infected tissue. Prognosis is poor despite optimal therapy with pulmonary mucormycosis mortality rates reported at 76% (Roden 2005). As with many rare systemic disease processes, minimal information is available on the best management approach of mucor in pregnant patients. This report describes the management approach of a gravid patient with pulmonary mucormycosis through the prenatal and peripartum period.
The patient is a 37-year-old G6P4 female with poorly controlled type 2 diabetes mellitus diagnosed with pulmonary mucormycosis at 28 weeks gestation after presenting with diabetic ketoacidosis, fever, cough, hemoptysis, and night sweats. CT scan showed right lower lobe consolidation with a 6.1 cm pulmonary abscess consistent with necrotizing pneumonia and additional patchy areas of consolidation in the right upper, middle, and lower lobes.
Given the lack of data regarding management of pulmonary mucormycosis in pregnancy, a multidisciplinary team was assembled involving obstetrics, thoracic surgery, infectious disease, pulmonology, neonatology, and obstetric anesthesiology. Consensus agreement was to proceed with surgical debridement given the extensive infection and mortality associated with pulmonary mucor. At 29 weeks gestation, the patient was scheduled for right open thoracotomy. The obstetric team had an extensive discussion regarding intraoperative fetal monitoring; the patient opted for no continuous fetal monitoring. A preinduction arterial line was established and general anesthesia was induced. Single-lung ventilation was maintained during thoracotomy without issue. Hemodynamics were managed with moderate doses of phenylephrine and norepinephrine infusions to maintain maternal blood pressure and placental perfusion pressure to optimize fetal oxygenation. Specific obstetric anesthesia techniques utilized included use of rectal indomethacin and volatile anesthetic to reduce uterine contractions. Ultimately, right middle and lower lobectomies were performed. Postoperatively, the patient required additional chest tubes for evacuation of pneumothoraces. Otherwise, her postoperative course was uneventful and pregnancy progressed without complications or onset of labor. The patient was discharged after three weeks to a local hospital for ongoing medical management with antifungal therapy. There were no signs of pulmonary insufficiency at that time with the patient maintaining oxygen saturations of 97-100% on room air.
At 36 6/7 weeks gestation, the patient delivered via repeat cesarean under CSE. Delivery was uncomplicated and the patient was discharged on postpartum day eight with ongoing stable respiratory status.
This case illustrates the importance of a multidisciplinary approach in the management of complex obstetric patients.