CTICasesPeripheral Rhizopus Infection with Necrotic Sequestrum and Empyema
Imaging findings
A neutropenic patient with E. coli bacteremia and persistent neutropenic fever, unresponsive to antibiotics, developed a peripheral area of consolidation with central necrosis that enlarged with surrounding ground glass but without the central bird's-nest of typical angioinvasive fungus. The left lung then collapsed from a developing empyema with parapleural thickening. Decortication and left lower lobe wedge resection yielded a roughly 2 cm ball of necrotic tissue (a sequestrum-like focus) that had come to lie in the pleural space, with fibropurulent pleural inflammation; cultures grew Rhizopus (order Mucorales).
Key takeaways
A peripheral, subpleural fungal infection with an evolving necrotic focus and empyema can behave atypically for angioinvasive fungus, and a subpleural location suggests bloodborne rather than inhaled spread. Here a Rhizopus (mucormycosis) infection produced a necrotic ball that sequestered into the pleural space with a complicating empyema, an unusual presentation confirmed on decortication and resection.
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