to the editor: Patients who have chronic obstructive pulmonary disease (COPD) are commonly treated with corticosteroids. This treatment may predispose such patients to opportunistic infections, including invasive fungal infections, that may initially manifest as hemoptysis. I would like to present the case of a patient with emphysema who had recently begun treatment with corticosteroids and who died as a result of hemoptysis due to invasive mucormycosis.
The patient was a 66-year-old man with alpha1-antitrypsin deficiency and severe emphysema. He smoked two packs of cigarettes per day for 35 years. The only medications he used were inhaled beta-agonists and ipratropium bromide. He had never been treated with corticosteroids. Four months earlier, he was treated with oral antibiotics and several courses of prednisone for increasing dyspnea and a productive cough. He did not use corticosteroids as maintenance between treatment courses.
Secondary to persistent symptoms, the patient was hospitalized. Physical examination revealed that he was in moderate respiratory distress with a temperature of 99°F, a heart rate of 98 beats per minute, a blood pressure 110/95 mm Hg and a respiratory rate of 24 breaths per minute. The cardiac examination was normal, lung sounds were diminished with expiratory wheezing, and there was no accessory muscle use or pulmonary consolidation. Chest radiograph revealed diffuse parenchymal abnormalities, and the patient was started on a course of intravenous antibiotics, methylprednisone and nebulized beta-agonist.
On day 10, massive hemoptysis developed and the patient was transferred to our institution. Repeat chest radiographs revealed a new opacity in the left lung, and bronchoscopy showed blood throughout the tracheobronchial tree. Pulmonary angiography demonstrated vascular ectasia and prominent bronchial vessels that corresponded with the opacity in the upper lobe of the left lung. Sputum and bronchoscopy cultures from the transferring hospital revealed the presence of Mucor species, and the patient was started on treatment with amphotericin B. Because of poor underlying lung function, the patient was not a suitable candidate for surgery.
Despite continued use of antibiotics, the patient died nine days after being transferred. Microscopic examination of the lungs at autopsy revealed tissue invasion with fungal hyphae, broad and ribbon-like with irregular wall thickness and non-septate hyphae, characteristic of Mucor species.
Invasive fungal infections are rare, but often fatal complications in patients with COPD. Such patients are often treated with corticosteroids, which predisposes them to the development of opportunistic infections through the depression of cell-mediated immunity and the impairment of macrophage killing.1 Some authors suggest that the risk of infection is minimal if patients who are treated with prednisone receive less than the equivalent of 10 mg per day, or a cumulative dose not exceeding 700 mg.2,3
Mucormycosis is not commonly reported in patients with COPD who are treated with corticosteroids. Common pulmonary pathogens in patients with COPD include Aspergillus, Pneumocystis carinii and Legionella pneumophila.2 Sixty-six percent of cases of pulmonary mucormycosis occur in patients with hematologic malignancies, and another 25 percent of cases occur in patients with diabetes.4,5 Antifungal treatment with amphotericin B is typically not effective. Occasionally, surgical resection has been successful; however, many patients with COPD are not candidates for lung resection, given their poor underlying lung function.5
This case illustrates that even low doses of corticosteroids, given for limited periods of time, may predispose patients with COPD to invasive fungal infections. This diagnosis should be considered in the differential diagnosis of patients with unexplained hemoptysis, in order to identify patients who are potential candidates for surgery.