CME INDIA Case Presentation by Dr. Nishith Kumar, MD, FAPSR, Consultant Department of Pulmonary Medicine, OMC, Ranchi.
There is only one case report where advance procedure like Cryo recanalization was done for the management of Endobronchial Mucormycosis.
CME INDIA Case Study
- 65-year-Old Male/ Post Covid 19/Uncontrolled Type II DM was referred to us with H/O Cough, Fever, Breathlessness for 1 month.
What was observed?
- Chest Radiology was suggestive of Right Whole Lung Collapse.
- Patient was a high-risk case in view of respiratory failure. Video bronchoscopy revealed an Endobronchial growth completely occluding the opening of Right Main Bronchus & extending till carina Multiple Endobronchial biopsies were taken and submitted for HPE.
What Microscopy revealed?
- Broad nonseptate hyphae with right-angled branching on Haematoxylin and eosin stain suggestive of Mucormycosis
What was done?
- Patient was duly started on dual Antifungal (Inj Liposomal Amp B + oral Posaconazole).. MRI PNS revealed no PNS/Orbital involvement.
- Despite >1 week of treatment with liposomal amphotericin B & posaconazole endobronchial mucormycosis leading to whole Right Lung persisted.
- Typically, pneumonectomy would have been performed, but the patient’s comorbidities & general condition made this course inadvisable. In addition, the lesion was so extensive that it would have been difficult to remove completely with surgical resection, including parts of the carina.
- So, we decided to proceed with bronchoscopic debridement/removal of endobronchial necrotic tissue using intervention techniques. This was done with the intent of relieving endobronchial obstruction & facilitating ongoing antifungal treatment by decreasing the fungal burden.
Using an advanced technique-Cryo-recanalization
- We used an advanced technique, cryo-recanalization using ERBE CRYO 2 System (First time in Jharkhand/Bihar) which uses freeze-thaw technique via a flexible bronchoscope.
- It results in immediate debulking of exophytic endotracheal tissue thus relieving obstruction. In this technique, the bronchoscopist retracts frozen tissue at the tip of the cryo-probe through a bronchoscope and gradually removes it resulting in recanalization of the airway lumen. This technique is feasible and has many advantages, including its use with flexible bronchoscopes, immediate efficacy, and low risk of complications.
Post Procedure CXR
Post Procedure Bronchoscopy
CME INDIA Learning Points
- ERBE CRYO 2 System can also be used for Trans Bronchial Lung Biopsies in cases of DPLDs.
- Surgical lung biopsy provides large size tissue, but there is associated morbidity, longer hospital stays, the risk of air leak, and mortality.
- Cryoprobe-TBLB provides larger biopsies than TBLB that are usually crush artifact free and enable the pathologist to provide diagnosis with greater confidence.
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