PMC9421258_01
Brain and Chest CT before and after surgery. (A) Brain CT before chemotherapy; (B) Chest CT before chemotherapy; (C) Day 30, a nodular lesion (3.2 cm x 2.8 cm, red arrow) in the post-basal segment of the left lower lobe with ground glass opacification; (D) Day 38, the initial nodular lesion was larger, and new lesion in the upper lobe of the right lung; (E, F). Day 52, the initial nodular lesion was 4.7 cm x 24.3 cm with part consolidation and the balloon cavity; the initial regional hazy shadow was spread diffusely in the left lung. (G) No regression of lesions and fungal flora in blood vessel on CTA (I) Brain CT on 6 months after surgery; (J) Chest CT on 6 months after lung lobectomy, no progression of mucormycosis.
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Before chemotherapy, the brain and chest computed tomography (CT) scan showed a negative result ( Figures 1A, B ). CRP levels were 1.73 ng/ml and 176.3 mg/l, respectively. Chest CT showed a nodular lesion (3.2 cm x 2.8 cm) in the post-basal segment of the left lower lobe with ground glass opacification ( Figure 1C ). On day 38, repeated CT showed a larger initial nodular lesion and a new lesion in the upper lobe of the right lung ( Figure 1D ). New regional shadows were seen in the upper lobe of the right lung ( Figures 1E, F ). Computer tomography angiography (CTA) was conducted and demonstrated no fungal flora in the blood vessels ( Figure 1G ). On day 66, surgical management involved the lower lobe of the left lung and pleura ( Figure 1H ). There was no progression of mucormycosis in the chest CT ( Figure 1J ) on 6 months after surgery. Brain CT was conducted after active persuasion, and it showed a good image ( Figure 1I ). The clinical course and timeline of the treatment course are summarized in  Figure 3  and  Table 1 .
Microscopic examination of the removed lung. (A-D). The tissue specimens were stained with hematoxylin and eosin staining. (A) Tissue necrosis (x40).
(B) Tissue necrosis (x200). (C) Fungal cenobium (black arrow) in the pulmonary alveoli (x200). (D) Filamentous fungi (red arrow) in the pulmonary (x100). (E) Filamentous fungi stained by PAS (x200). (F) Gomori methenamine silver stain of a fungal cenobium (Grocott, x200).
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A microscopic examination revealed tissue necrosis ( Figures 2A, B ), fungal cenobium in the pulmonary alveoli ( Figure 2C ), and filamentous fungi in the removed pulmonary specimen ( Figure 2D ). It was positive for periodic acid Schiff (PAS) stain (  Figure 2E ) and Gomori methenamine silver stain ( Figure 2F ) but negative for acid-fast stain.
The clinical course of the patient. The patient had fever on day 28 and persistent fever for several days. Fever subsided after amphotericin B and posaconazole treatment. The ANC and CRP data were also obtained. The temperature was gradually increased on day 23 and peaked on day 34. A blood count revealed persistence of neutropenia and severe neutropenia on day 30. On day 66, surgical management was performed. On day 84, the patient started the second induction therapy.
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The clinical course and timeline of the treatment course are summarized in  Figure 3  and  Table 1 .