Moldy Hay and the Cirrhotic Farmer: The First Case of Peniophora Lung Infection

Author:

L. Miranda1, O. Epelbaum2, H. Assallum3, G. Miranda4;

Author address:

1Westchester Medical Center, Valhalla, NY, United States, 2Pulmonary/Critical Care/Sleep, Westchester Medical Center, Valhalla, NY, United States, 3Westchester Medical Center, Fort Lee, NJ, United States, 4Essen Medical Associates, Bronx, NY, United States.

Full conference title:

The American Thoracic Society Conference 2018

Date: 19 November 2018

Abstract:

INTRODUCTION: Advanced liver cirrhosis has been noted to be a risk factor for various forms of invasive fungal infection, including pulmonary aspergillosis and cryptococcal meningitis. The predisposed patient with liver disease also needs to have the appropriate environmental exposure. We describe a unique case of a cirrhotic horse farmer who acquired sequential lung mold infections, the second with a pathogen heretofore not associated with human infection.
CASE PRESENTATION: 54-year-old horse breeding ex-smoker with alcoholic cirrhosis, hepatocellular carcinoma, and uncontrolled diabetes was found to have an abnormal routine chest CT during liver transplant evaluation. The patient’s only complaint was a chronic productive cough. He was afebrile. Physical examination and initial laboratory studies were unrevealing. CT showed a 2.6cm mass-like consolidation in the right lower lobe associated with intrathoracic lymphadenopathy. EBUS-TBNA of the lymph nodes was non-diagnostic, whereas EBUS-TBNA of the parenchymal lesion yielded neutrophils consistent with abscess. TBNA fungal culture of the lesion was negative, but the BAL fungal culture grew A.fumigatus along with S. pneumoniae, H. influenza, and Rothia spp. The patient was started on isavuconazole, then switched to voriconazole once confirmed to be sensitive. He also completed an antibacterial course. Repeat CT 3 months later showed interval growth of the parenchymal lesion, prompting repeat bronchoscopy (Figure). Thick mucus was noted in the area of abnormality; BAL fungal culture grew Peniophora spp. Once again, multiple bacterial pathogens were also recovered. BAL galactomannan and aspergillus PCR were negative, and there was no Aspergillus growth on culture. The patient was started on Amphotericin but experienced an infusion reaction, which prompted a switch to isavuconazole. Repeat CT 3 months after the second bronchoscopy showed significant improvement of the RLL process.
DISCUSSION: Peniophora is a fungal genus of plant pathogens that usually inhabit tree bark. This organism has not been previously associated with human infection. Our patient is a farmer exposed to horses, hay, and trees, which is what likely placed him in contact with this mold as well as Aspergillus. He exhibited multiple possible risk factors for lung infection with an opportunistic mold normally incapable of causing human disease. His underlying liver cirrhosis was probably primary among them. Others include uncontrolled diabetes, cancer, and the potential facilitative role of concomitant bacterial growth. It is also intriguing that Peniophora was isolated and implicated in his worsening pneumonia only after Aspergillusappeared to have been adequately treated, suggesting selection pressure imposed by voriconazole therapy.

Abstract Number: A5467 / P1246

Conference Year: 2018

Link to conference website:

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