Case Presentation: A 59-year old man presented with high grade fever (102 F), non-productive cough, and malaise for two months duration. His medical history was significant for of relapsing Chronic lymphocytic leukemia; on chemotherapy, Chronic kidney disease, and invasive pulmonary aspergillosis diagnosed a year ago and treated with a 12-week course of voriconazole. Initial laboratory investigations revealed pancytopenia with a hemoglobin of 7.6 g/dL, leukocyte of 4.9 103/microL with Absolute neutrophil count of 0.05, and platelets of 16 103/microL. Chest CT showed areas of consolidation and nodularity on the right side. Bronchoalveolar lavage (BAL) revealed hyphae on fungal smear and fungal culture had few penicillium. Polymerase chain reactions for Histoplasma, Blastomyces, and Pneumocystis jiroveci, and Aspergillus Ag were negative. Fungitell was positive(148 pg/mL). Patient was treated with Caspofungin and the initial repeat CT showed stabilization of his nodular infiltrates. However, his symptoms worsened over the next few weeks. Repeat imaging showed progression of previous nodules and a new nodular infiltrate in the right inferior lobe with consideration, suggestive of atypical fungal infection. Blood and sputum cultures were negative again. Repeat fungal serology for Blastomyces, Coccidioides, Histoplasma, and Cryptococcus Ag were all negative. BAL fluid grew filamentous fungus that was identified as Scopulariopsis species, a dematiaceous mold that can cause invasive infection in immunosuppressed patients. Patient also developed an erythematous ulcerated nodule on the scalp and biopsy culture from this lesion also grew Scopulariopsis. The patient was treated with combination therapy of liposomal Amphotericin, caspofungin, and terbinafine. However, patient’s condition deteriorated with new polymicrobial bloodstream infection with Fusobacterium and Enterocococcus with ongoing neutropenic fevers and he was transitioned to comfort care.
Discussion: Invasive mold infections have become more common due to the increased use of immunosuppressive therapies to treat a variety of conditions. Rare molds such as Scopulariopsis species have emerged as cause of invasive disease in immunocompromised patients. A case series (Iwen et al.2012) reported 38 cases of Scopulariopsis infection and seven of these were disseminated. Tissue cultures, histopathologic evaluation of morphologic features, and molecular sequencing of the tissues have been used to identify this rare mold.
Conclusions: • Breakthrough fungal infection due to drug-resistant mold may occur in severely immunocompromised patients on antifungal prophylaxis. • A thorough physical exam may reveal foci of metastatic seeding, such as scalp lesion in this case. Tissue microscopy of skin lesions can confirm the diagnosis of disseminated fungal infection.