Breakthrough invasive pulmonary Coprinopsis cinerea (Hormographiella aspergillata) infection successfully managed with antifungal therapy and surgical resection enabling cord blood transplantation

Coprinopsis cinerea (C. cinerea, also known as Hormographiella aspergillata) is a rare basidiomycete that causes invasive fungal infections in immunocompromised patients and is often difficult to diagnose microbiologically. We report a case of breakthrough proven invasive pulmonary fungal infection caused by C. cinerea during antifungal prophylaxis in a patient with acute myeloid leukemia undergoing induction chemotherapy. During the neutropenic phase, chest computed tomography (CT) revealed a nodular lesion in the right lower lobe that progressed despite antifungal prophylaxis, raising suspicion of invasive mold infection. Antifungal therapy was switched to liposomal amphotericin B. Transbronchial lung biopsy demonstrated septate fungal hyphae, although fungal cultures remained negative. Molecular analysis using polymerase chain reaction on paraffin-embedded lung tissue subsequently identified C. cinerea. Radiological findings worsened after initiation of liposomal amphotericin B and reached peak severity on the first follow-up CT, followed by early radiological improvement on the subsequent CT examination, after which step-down therapy with isavuconazole was initiated for safety and tolerability. To eliminate residual infection and minimize the risk of post-transplant relapse, thoracoscopic lobectomy was performed, and pathological examination showed granulomatous inflammation without viable fungal elements. The patient subsequently underwent cord blood transplantation and remains in remission without recurrence of fungal infection. This case highlights the importance of tissue diagnosis, molecular identification, appropriate antifungal therapy, and surgical intervention in controlling breakthrough invasive fungal infection and enabling successful hematopoietic stem cell transplantation.