Verruconis gallopava pulmonary infection in a patient with Cushing’s syndrome

ABSTRACT Background Verruconis gallopava is a dematiaceous mold that rarely causes human infection except in immunocompromised patients, such as those with solid organ transplants or hematologic malignancies. We describe an unusual case of pulmonary V. gallopava infection in a patient with undiagnosed Cushing’s syndrome. Case Summary A 48-year-old woman was admitted to the hospital for Staphylococcus aureus bacteremia, along with a history of recurrent falls and uncontrolled atrial fibrillation. As part of her investigations, she was noted to have an incidental lung nodule that was progressing in size, with evidence of cavitation over a 3-month period. A transbronchial biopsy revealed histopathologic findings consistent with phaeohyphomycosis, and bronchoscopy specimens grew V. gallopava . Fungal identification was confirmed via internal transcribed spacer and D1/D2 sequencing, as well as with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. After further investigation, the patient was diagnosed with Cushing’s syndrome secondary to an adrenal secretory mass and underwent left adrenalectomy, with subsequent clinical improvement. Repeat imaging following adrenalectomy showed radiographic resolution of her pulmonary nodule without initiation of antifungal treatment, consistent with clearance following immune reconstitution. Conclusion This is the first reported case of invasive V. gallopava infection that self-resolved following immune reconstitution and without the need for antifungal therapy. V. gallopava is a rare cause of invasive fungal disease in immunocompetent patients, and workup for possible underlying immunodeficiency should be considered in patients with V. gallopava infection.