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Invasive Transmural Fungal Infection: A Rare Cause Of Thoracic Aortic Occlusion
Joanna F. Shaw, MD, MS, Benjamin Emert, MD, Jesus Ulloa, MD, Vincent Rowe, MD.
UCLA, Los Angeles, CA, USA.
DEMOGRAPHICS15 year old male presented with splenic rupture, new diagnosis of acute lymphoblastic leukemia.HISTORYHe underwent splenectomy with staged open abdomen, followed by fascial closure. Induction chemotherapy was initiated with resulting neutropenia. He developed pleural effusions requiring percutaneous drainage with concern for descending thoracic aortic injury. Cross-sectional imaging with reported liver hematoma, pneumomediastinum, and descending aortic injury. Imaging review by vascular surgery with no periaortic hematoma or evidence of intra-mural hematoma; however, there was finding of intraluminal thrombus with high grade stenosis.PLANPrimary service was advised to begin systemic anticoagulation for high grade stenosis of descending thoracic aorta and risk of thrombo-embolization. Evaluated by gastroenterology with placement of esophageal stent for pneumomediastinum. Patient became progressively septic requiring vasopressor support and developed clinical findings suggestive of aortic occlusion. Repeat imaging with occlusion of descending thoracic aorta in addition to right pulmonary thrombus and new bi-atrial thrombus. Patient subsequently expired, and postmortem autopsy demonstrated disseminated Mucormycosis with Rhizopus species involving esophagus, aorta, right atrium, and lungs.DISCUSSIONOn autopsy, there was transmural fungal infection in the esophagus with extensive periesophageal fungal exudate, mural invasion of the thoracic aorta with an associated fungal thrombus, and no evidence of aortic dissection or perforation. Altogether, these findings suggest initial invasive fungal infection of the esophagus leading to perforation and extension into the thoracic aorta, with subsequent dissemination into the pulmonary vasculature, right atrium, and inferior vena cava. Angio-invasive fungal species are often difficult to diagnose and contribute to high rates of mortality among immunocompromised patients. Secondary procedures, and interpretation of cross-sectional imaging may cloud clinical evaluation which highlights the need for independent review of imaging by consulting vascular surgeons. Early consideration of fungal infection may facilitate medical care discussion, and the role of operative interventions.
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