Case presentation
A 52-years-old woman with a history of uncontrolled diabetes, HbA1C level of 12%, and hypothyroidism for about 6 years, was referred to the hospital due to productive cough, hemoptysis, fever, and chills started two months before, and it was accompanied by shortness of breath. The drug history was metformin and oral Glibenclamide. At the time of admission, she had a fever of 38° centigrade, a 95% oxygen saturation level, a respiratory rate of 23, and a heart rate of 90. In the physical examination, she was pale; the cardiac auscultation was normal and, in the skin examination the scars of the abdomen were evident. On the initial auscultation of the lungs, there was a decreased sound at the base of the left lung and she had fever. In blood tests, she had a high titer of erythrocyte sedimentation rate (ESR) and 3+ C-Reactive Protein (CRP).
Due to pulmonary symptoms, she was repeatedly treated with antibiotics during this period which didn’t have a clinical response. In our hospital, after observing the symptoms in favor of hydatid cyst in lung computed tomography (CT-scan) (Figure 1. A), the patient underwent a biopsy, and after reporting a positive serology for hydatid cyst, medical treatment with two albendazole tablets, once daily, was initiated. The patient’s symptoms continued until she underwent a thoracotomy and resection of the left lower lung cyst. During the surgery a sample was taken from another cavity located next to the resected cyst. (Figure 1. B)
In pathology report in left chest wall lesion resection ”consist with hydatid cyst accompanied by foreign body reaction ” and in the left lung, lower lesion resection, ”lung tissue with hemorrhage, congestion, infiltration cells with neutrophil predominance and groups of large, nonseptic hyphae with variable width, 90-degree angle branching and non-parallel walls consistent with Mucormycosis ” were noted (Figure 2).
After surgery and confirmation of coexistence of lung hydatid cyst and Mucormycosis, the patient was treated with liposomal amphotericin B 5mg/kg=300 mg daily for 4 weeks and hydatid cyst medical therapy also continued with albendazole 80 mg daily. After 4 weeks of treatment with amphotericin B, lung CT-scan reported an improvement in the condition (Figure 1. C). During the four weeks treatment period, the patient’s symptoms were stable and she did not have fever and chills and did not report any complaints about the previous symptoms.
The oral treatment continued and the patients was discharged for 2 weeks with good general condition. For maintenance therapy, the patient received itraconazole 200mg tablets, BID to complete 6 weeks of treatment. At the end of 6 months of follow-up, she had no pulmonary complaints and clear radiological evidence was noted in lung CT-scan. (Figure 1. D) and after two weeks, she was revisited without any particular complaints.