Introduction

Pulmonary mucormycosis is a potential complication in patients with diabetic ketoacidosis. Isolation of filamentous fungus from bronchoscopy specimens of this population may prompt clinicians to include pulmonary mucormycosis in their differential diagnoses and initiate high-dose intravenous liposomal amphotericin (>5 mg/kg/day). Amphotericin is an expensive therapy and is frequently associated with adverse effects such as nephrotoxicity, phlebitis, and acute febrile reaction. We encountered a case in which pulmonary aspergillosis rather than mucormycosis was diagnosed in a patient with diabetic ketoacidosis.

Method

A 36-year-old female with history of type 1 diabetes was admitted to an intensive care unit due to increased work of breathing and decreased Glasgow coma scale (14). She presented with a temperature of 33.4 Celsius, glucose 39 mmol/L, beta-hydroxybutyrate 11.4 mmol/L, and blood gas of pH 6.94, bicarbonate 5 mmol/L, carbon dioxide partial pressure 24, and lactate 1.6 mmol/L. Computed tomography showed extensive parenchymal disease with reticulation and air space opacity and well circumscribed nodules distributed throughout the lungs (largest 14 mm). (Figure 1 https://drive.google.com/file/d/16_Tw4Uoa2FbavqeM5_u7IomSOTeoMOo0/view?usp=sharing). Bronchoalveolar lavage specimens were sent to the microbiology laboratory, where heavy growth of filamentous fungus was identified on culture plates (Figure 2 https://drive.google.com/file/d/1CSIng6R2YYDfAt9evfVnVm6zvLspKvvV/view?usp=sharing).

Results

The fungus isolates were examined under 400x magnification with lactophenol blue stain and identified as Aspergillus nigers (Figure 3 https://drive.google.com/file/d/1Qjd-CCyIusivBVLfX0uTc2GsijpMp0oV/view?usp=sharing) and Aspergillus flavus (Figure 4 https://drive.google.com/file/d/1-4nY7_RInykv-HWUXuGF-IZ-8VT-E_ra/view?usp=sharing). The patient was given 200 mg intravenous voriconazole every 12 hours, a first-line therapy for aspergillosis. She achieved clinical improvement and was later discharged home.

Conclusion

Like pulmonary mucormycosis, pulmonary aspergillosis could happen in patients with diabetic ketoacidosis and should be kept in the differentials. The first-choice therapy differs for pulmonary mucormycosis and aspergillosis.