The patient, male, 51 years old, medical worker in the Department of Anesthesiology, was admitted to the Department of Respiratory Medicine of the First People's Hospital of Tianmen City for treatment on September 21, 2020 due to "intermittent chest pain and cough for more than 5 months"
The patient was admitted to Department of Infectious Diseases of our hospital for treatment due to 'chest pain for 3 days' on March 26, 2020.On March 20, 2020. At this moment, All COVID-19 patients in Tianmen City, Hubei Province were cleared. Physical examination: the pharynx was not red, bilateral tonsils were not large, superficial lymph nodes were not large, respiratory sounds in both lungs were rough, and no rales of dry or wet were heard. The patient had been tracheally intubated in a patient with COVID-19. The clinical diagnosis was "viral pneumonia and bronchiectasis" based on medical history, physical examination and ancillary tests. and was treated with anti-infective (moxifloxacin), anti-viral (Abidol) and symptomatic supportive treatment. 12 days in hospital, chest pain, chest tightness, shortness of breath, cough and other symptoms relieved and discharged.
Due to 'chest pain and discomfort', accompanied by chest sulking and short breath after activities", the patient was hospitalized for many times, with poor results. Later, the patient was transferred to the First Affiliated Hospital Of Guangzhou Medical University. Patient’s BALF was tested by mNGS on September 3 (Fig. 3), combined with medical history, clinical manifestations, and auxiliary examination results, he was diagnosed with mucormycosis (Lichtheimia ramose infection). Past history: history of acute renal insufficiency in 2016;No history of hypertension, coronary heart disease, diabetes, tuberculosis, hepatitis; Has a history of allergy to ginseng wheat. Since the onset of the disease, appetite loss, slightly poor spirit.
Auxiliary examination: The patient was admitted to the hospital on March 26 for routine blood tests with a slightly high neutrophil ratio (78.5%, normal range: 40%-75%) and a slightly low lymphocyte ratio (14.70%, normal range: 40%-75%). Interleukin-6 (IL-6) was 28.68 pg/ml (reference range: < 7 pg/ml); liver and kidney function, coagulation function, ESR, respiratory viruses were not significantly abnormal, and SARS-CoV-2 was negative. The patient's blood count began to rise in April (Table 1). During the course of the disease,the changes in the patient's blood count are detailed in Table 1.
Table 1
Changes in blood routine, C-reactive protein, and ESR during hospitalization
Test items | Reference range | Mar-26 | Mar-27 | Apr-3 | Apr-24 | Aug-18 | Aug-29 | Sep-23 |
WBC(×109/L) | 3.5–9.5 | 8.02 | 6.76 | 5.57 | 5.16 | 10.54 | 7.54 | 6.02 |
NEU#(×109/L) | 1.8–6.3 | 6.29 | 5.36 | 3.98 | 3.61 | 9.42 | 5.87 | 4.45 |
NEU% | 40–75 | 78.50 | 79.20 | 71.40 | 69.90 | 89.30 | 77.90 | 74.00 |
LYM#(×109/L) | 1.1–3.2 | 1.18 | 0.83 | 0.84 | 0.68 | 0.67 | 1.13 | 0.83 |
LYM% | 20–50 | 14.70 | 12.30 | 16.90 | 13.20 | 6.40 | 15.00 | 13.80 |
CRP(mg/L) | ≤ 6 | 9.99 | 11.32 | 5.15 | 8.96 | 35.08 | 5.77 | 35.94 |
ESR(mm/h) | 0–20 | - | 11 | 68.2 | - | 56 | 30 | 45 |
On March 26,The first Computed tomography (CT) at the first admission (Fig. 1.A) The chest CT suggested infectious lesions in both lungs, with multiple patchy ground glass shadows with blurred margins in both lungs, with more obvious lesions in the right lower lung and bilateral pleural thickening and adhesions. The patient was readmitted on April 23, a repeat chest CT (Fig. 1.B) suggested that multiple patchy and striated high-density foci were seen in both lungs, with blurred margins of some of the foci, and the foci in the lower lobe of the right lung were slightly larger than before, with new small patchy ground-glass density foci in the anterior segment of the upper lobe of the right lung, and the foci in the lower lobe of the left lung were slightly reduced in size. A repeat chest CT (Fig. 1.C) on May 29 suggested that multiple patchy and striated high-density foci were seen in both lungs. On August 29, a repeat chest CT showed multiple patchy and striated high-density foci in both lungs, with a slight reduction in the extent of the foci in the lower lobe of both lungs, new ground glass-like and patchy solid high-density foci in the upper lobe of the right lung(Fig. 1E) and the lower lobe of the left lung (Fig. 1D), with poorly defined borders. On October 1, the chest CT (Fig. 1F) showed partial cavity formation in the right upper lung and a small amount of fluid in the right pleural cavity .On November 30, the chest CT (Fig. 1G) showed the cavity formation in the right upper lung was slightly smaller than before, and the right pleural effusion had basically disappeared. H, On May 27,2021, the chest CT (Fig. 1H) showed showed a partially reduced lesion in the upper lobe of the right lung and the cavity in the lesion was reduced.
Pathology and etiological examination: CT-guided percutaneous lung biopsy was performed on April 24, Lung biopsy tissue submitted for pathological examination and pathogenic examination. Tissue biopsy revealed: coagulative necrosis of some alveolar tissue(Fig. 2A), fibrin-like exudates in tissue cells in the alveolar cavity, and fibers and blood vessels at the edges of necrotic alveolar tissue Hyperplasia(Fig. 2B), Fungal fluorescence staining (negative)(Fig. 2).The tissue was stained to find bacteria and fungi: bacteria, fungal hyphae and spores were not found; tissue culture (common bacteria, anaerobic bacteria, fungi): no bacterial growth.
On September 21,The patient was transferred to the First People's Hospital of Tianmen City (Respiratory and Critical Care Medicine Department) for continued treatment. Based on the patient's medical history, clinical presentation, mNGS, and Based on the patient's history, clinical manifestations, mNGS, CT and other examination results, the patient was considered to have a pulmonary fungal infection with Lichtheimia ramosa as the pathogenic organism, and was treated with amphotericin B antifungal therapy at a dose of 30 mg/10h intravenously pumped. During the hospitalization, the blood potassium was low, and the urea and creatinine were increased (Table 2), and symptomatic treatments such as potassium supplementation and kidney protection were performed. On October 12, Examination of chest CT showed that most of the lesions were reduced in size, and the upper right lung cavity was reduced (Fig. 1F).The patient's cough and chest tightness were relieved, he was dischargedand amphotericin B was continue oral at outpatient service.
Table 2
Changes in serum potassium, urea, and creatinine during hospitalization
Test items | Reference range | Aug-29 | Sep-23 | Sep-25 | Sep-27 | Sep-29 | Oct-1 | Oct-4 |
K(mmol/L) | 3.5–5.3 | 4.61 | 3.22 | 3.02 | 2.72 | 2.91 | 3.34 | 3.56 |
Urea(mmol/L) | 3.1-8 | 4.55 | 8.63 | 7.73 | 7.25 | 6.35 | 8.11 | 8.75 |
CREA(mmol/L) | 57–97 | 90.1 | 140.1 | 132.7 | 136.4 | 127.1 | 163.4 | 138.3 |