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5. 1 & 2
Both TEE and workup for APLS should be considered. In the setting of multiple organ infarcts, one should think about septic emboli, cardiac embolic phenomena, mycotic aneurysms, hypercoagulable states, and vasculitic conditions. His blood cultures were repeatedly negative over the > 2 week course, as well as all other negative cultures to date. Therefore, there was consideration for HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella corrodens, Kingella) organisms in endocarditis, fastidious bacteria such as Nocardia or Actinomyces, other infectious mycotic aneurysm, and fungal infections especially ones with poor sensitivity to growth on blood cultures. Additionally, a non-infectious embolic source also can present as in this case and should be entertained.
Performing a liver biopsy or splenectomy would be risky given the potential for septic spread and bleeding, and, if infarcts are present, there may be low yield. Furthermore, the donor kidney was explanted and thus performing another biopsy or obtaining pathology of another organ would probably be unnecessary and with added risk.
The patient did undergo TEE which was negative. APLS workup also was negative. We did perform a CTA to evaluated for mycotic aneurysm as well for progression of the cavitary lung lesion - these tests were negative. A few days later, after a period of defervescence, the patient returned again to the ICU with progressively worsening abdominal pain, a CT revealing increasing amount and size of organ infarcts as well as evidence of a lateral wall of myocardium appearing to be infarcted, and with signs and symptoms of an acute STEMI. He was urgently taken to the cardiac catherization lab revealing an occluded left circumflex of which he underwent PCTA, and then to follow, he was taken to the OR where another exploratory laparotomy was performed. The spleen was infarcted and there was an ischemic-appearing gastric cardia and small bowel and necrotic tissue in the retroperitoneum. No abscess, stool, purulence or enteric contents was noted in the peritoneal cavity, and the necrotic tissue was too friable and there would have been an elevated risk of bleeding for any surgical intervention.
CT was also concerning for a peri-splenic abscess, an area of newly loculated left pleural effusion and now with a skin lesion on his right abdomen with central necrosis and a rim of dusky mottled appearance. Drains were placed both in the peri-splenic abscess and in the pleural effusion, with growth of GNR, and following the drains, a skin biopsy was performed.
Patient decompensated later that evening, progressing to a state of shock and died later that night. The fluid grew Bactericides fragilis and Rhizopus species. The skin biopsy was positive for fungal elements resembling mucoracae. And the final autopsy report confirmed the diagnosis of disseminated mucormycosis with associated multi-organ infarcts with noted fungus with each organ involved.
What is the best first-line anti-fungal treatment for mucormycosis? (Click on the correct answer to proceed to the fourth of five panels)