[Conidiobolomycosis (rhinofacial entomophthoromycosis) in Gabon. About of one case]

Background

Entomophthoromycosis constitutes a nosological group of subcutaneous mycoses including conidiobolomycosis (rhinofacial form) and basidiobomomycosis (subcutaneous form involving the trunk and the limbs). Conidiobolomycosis is characterized by a progressive nasal and facial deformity giving, in the evolved forms, a "hippopotamus snout". The literature review finds a hundred cases, with a tropism for the humid tropical regions. Methods. We report the observation of a 25-year-old patient, living in the equatorial zone, in the south of Gabon in a humid forest area, presenting a swollen aspect of the face mainly involving the eyelids, the nose and the upper lips.

Results

The diagnosis of entomophthoromycosis was compatible with the histopathological and clinical aspects. The evolution was favorable in terms of facial aesthetics under itraconazole 300 mg/day for 2 months and corticosteroid therapy (bolus of methylprednisone 240 mg/day for 3 days relayed per os at a dose of 0.5 mg/kg/day, i.e. 30 mg/day) of prednisone), maintained for 3 months. The average nasal improvement could not be completed by surgery and the patient was lost to follow-up.

Conclusion

This second observation of conidiobolomycosis in Gabon in the same province makes Ngounié a privileged ecosystem for this affection.

Human Pathogenic Entomophthorales

The pathogenic entomophthoralean fungi cause infection in insects and mammalian hosts. Basidiobolus and Conidiobolus species can be found in soil and insect, reptile, and amphibian droppings in tropical and subtropical areas. The life cycles of these fungi occur in these environments where infecting sticky conidia are developed. The infection is acquired by insect bite or contact with contaminated environments through open skin. Conidiobolus coronatus typically causes chronic rhinofacial disease in immunocompetent hosts, whereas some Conidiobolus species can be found in immunocompromised patients. Basidiobolus ranarum infection is restricted to subcutaneous tissues but may be involved in intestinal and disseminated infections. Its early diagnosis remains challenging due to clinical similarities to other intestinal diseases. Infected tissues characteristically display eosinophilic granulomas with the Splendore-Höeppli phenomenon. However, in immunocompromised patients, the above-mentioned inflammatory reaction is absent. Laboratory diagnosis includes wet mount, culture serological assays, and molecular methodologies. The management of entomophthoralean fungi relies on traditional antifungal therapies, such as potassium iodide (KI), amphotericin B, itraconazole, and ketoconazole, and surgery. These species are intrinsically resistant to some antifungals, prompting physicians to experiment with combinations of therapies. Research is needed to investigate the immunology of entomophthoralean fungi in infected hosts. The absence of an animal model and lack of funding severely limit research on these fungi.

Emergence of gastrointestinal basidiobolomycosis in the United States, with a review of worldwide cases

BACKGROUND

We examined the epidemiology, clinical manifestations, histopathology, management, and outcomes of gastrointestinal basidiobolomycosis, an uncommon manifestation of infection caused by the fungus Basidiobolus ranarum.

METHODS

In this retrospective observational cohort study, cases of gastrointestinal basidiobolomycosis in the United States were identified by reviewing medical records from Mayo Clinic Hospital (Phoenix, AZ) and contacting local infectious diseases specialists, pathologists, gastroenterologists, the Arizona Department of Health Services, health departments of adjacent states, the Armed Forces Institute of Pathology, and the US Centers for Disease Control and Prevention. A comprehensive literature review identified additional cases worldwide.

RESULTS

Of 44 patients (mean age, 37 years [range, 2-81 years]) with gastrointestinal basidiobolomycosis, most were from the United States (19 patients [43%], of whom 17 [89%] were from Arizona) or Saudi Arabia (11 [25%]). Most (28 [64%]) were previously healthy. Common chronic medical conditions among 15 patients (34%) were diabetes mellitus (8 patients [18%]) and gastric disorders (7 [16%]). Common findings were abdominal pain (37 patients [84%]) and a palpable abdominal mass (19 [43%]). Intraabdominal malignancy was the leading provisional diagnosis (19 patients [43%]). The large bowel was involved in 36 (82%), the small intestine in 16 (36%), and the liver or gallbladder in 13 (30%). Characteristic histopathologic findings were observed in 43 (98%). Eight patients (18%) died. Combined surgical intervention and antifungal therapy was the preferred treatment.

CONCLUSIONS

Gastrointestinal basidiobolomycosis is an emerging invasive fungal infection in desert regions of the US Southwest. Clinical findings mimic malignancy and inflammatory bowel disease. Surgical excision and prolonged antifungal therapy are associated with favorable outcomes.

Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome

OBJECTIVE

To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period.

METHODS

Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck.

RESULTS

Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001).

CONCLUSIONS

In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Sudden vision loss caused by rhino-orbital zygomycosis in diabetic patients: case series

Rhino-orbital zygomycosis is a life-threatening fungal infection generally occurring in patients with an underlying disorder, such as diabetes mellitus with ketoacidosis or with immunocompromising factors, although it may rarely appear in healthy individuals. The study has been undertaken to discuss the clinical presentation, pathogenesis, diagnostic work up and management of this rapidly progressive disease. Four male patients having uncontrolled diabetes and presenting with signs and symptoms of rhino-orbital zygomycosis were studied to illustrate the serious nature of the disease. All the four patients had rapidly deteriorating vision loss either unilateral or bilateral along with other nasal and orbital signs and symptoms. All the patients were put on liposomal amphotericin B and underwent orbital exenteration and pansinusectomy. One patient died, while the other three were successfully treated. Early diagnosis is critical in the prevention of morbidity and mortality associated with the disease. There is need for a high index of clinical suspicion in immunocompromised patients. Timely medical-surgical treatment proves extremely important for prognosis.

[Zygomycosis]

Zygomycosis is an invasive fungal infection with extremely high mortality caused by filamentous fungi which belong to Class Zygomycetes (Rhizopus spp., Mucor spp., Cunninghamella spp., etc). Despite of the similarities of the ecological characteristics and of the patients' backgrounds, zygomycosis is much rarer than invasive aspergillosis. In addition to well known immunosuppressive risk factors (hematological malignancy, hematopoietic stem cell or solid organ transplant, prolonged neutropenia, corticosteroid, etc), diabetic ketoacidosis, iron overload, and administration of deferoxamine are specific factors predisposing zygomycosis. Rhinocerebral, pulmonary and disseminated disease is characteristic forms. The mainstay of the treatment is surgical resection, reversal of immunosuppressive factors, and administration of high-dose amphotericin B or its liposomal formulation. Because of the difficulty of culture detection and the absence of reliable serological diagnostic methods, premortem diagnosis and no delaying of effective treatment remain a challenge to physicians.

[Zygomycetes and zygomycosis in the new era of antifungal therapies]

Zygomycosis or mucormycosis is the third most invasive fungal infection after candidiasis and aspergillosis. Traditionally, it has been considered a community-acquired disease, but it is becoming a frequent nosocomial-acquired disease. Recently, several publications from different institutions have reported an increase in the number of cases of invasive zygomycosis as a result of the new antifungal and immunosuppresive therapies and the emerging immunocompromised population. In addition, the diagnosis of zygomycosis is elusive, mainly in pulmonary and disseminated forms. One of the main limitations in isolating Zygomycetes from clinical samples is the interpretation of results. The increasing number of invasive fungal infections caused by multiresistant fungi has led to the development of new antifungal drugs with variable activity against Zygomycetes.

[Invasive zygomycosis: notably in diabetes mellitus and iron overload]

The incidence of invasive zygomycosis, a severe and often life-threatening infection, is increasing. The most common manifestations are pulmonary infection (following anti-cancer chemotherapy or haematopoietic stem-cell transplant) and invasive rhinocerebral infection (in patients with diabetes mellitus or iron overload). Iron metabolism plays an important role in the pathogenesis of infection in these high-risk populations. Rapid diagnosis, reversal of the underlying predisposition and timely surgical debridement are the underlying principles of therapy for this disease.

Primary cutaneous zygomycosis in two immunocompromised children

Zygomycosis, often referred to as ''mucormycosis'' or ''phycomycosis,'' is a rapidly progressive fungal infection which usually occurs in immunocompromised individuals, and is characterized by soft tissue destruction and invasion of blood vessels. The rare and easily misdiagnosed primary cutaneous form may present as a superficial erosion with a painless, gradual onset and slow progression of symptoms or a gangrenous, necrotic ulceration due to rapid tissue and vascular invasion. With the latter form, the mortality rate among affected individuals is high even after aggressive surgical debridement and amphotericin B administration, emphasizing the importance of early recognition and proper diagnosis. We present two instances of gangrenous cutaneous zygomycosis in immunocompromised children and review the literature with regard to etiology, diagnosis and treatment, highlighting the pediatric population.

Contemporary Treatment and Outcomes of Zygomycosis in a Non-oncologic Tertiary Care Center

BACKGROUND

Zygomycosis is an emerging mycosis of increasing relevance. Limited data exist for outcomes with contemporary therapies.

METHODS

A 6-year retrospective chart review was performed in a non-oncological tertiary care center for patients with zygomycosis.

RESULTS

Sixteen episodes of proven (EORTC/MSG criteria) zygomycosis were identified. The average age was 49.2 years. Sites of infection were surgical/traumatic wound [5], rhinocerebral [4], disseminated [2], pulmonary [2], peritoneal [2], and localized skin [1]. Associated conditions included diabetes [7], ketoacidosis [2], end-stage renal disease [4], surgery/trauma [4], steroids [3], solid organ transplant [2], neutropenia [1], and intravenous drug use [1]. Twelve patients had surgical debridement. Medical therapy included liposomal amphotericin B, conventional amphotericin B (CAB), and amphotericin B lipid complex. Overall mortality was 4/16 (25%), occurring in a patient each with rhinocerebral, pulmonary, surgical wound infection, and disseminated disease. Mortality with surgical treatment was 2/12 (17%) vs. 2/4 (50%) without surgery. Mortality for patients treated with CAB was 1/3 vs. 3/12 for those treated with any lipid preparation. Serious morbidity occurred in 7/12 survivors.

CONCLUSIONS

In this limited study of contemporary therapies, patients with zygomycosis from a non-oncological tertiary care center have lower mortality than classically described. This disease and its treatments are still associated with severe morbidity, disfigurement, and disability.

Zygomycosis: the re-emerging fungal infection

Invasive fungal infections are major medical complications in immunocompromised patients. The recent rise in the incidence of cancer and the increased use of newer medical treatment modalities, including organ transplantations, have resulted in growing numbers of highly immunosuppressed individuals. Although aspergillosis and candidiasis are among the most common invasive mycoses in such patients, there is evidence that the incidence of infectious diseases caused by Zygomycetes has risen significantly over the past decade. Patients with diabetes, malignancies, solid organ or bone marrow transplants, or iron overload and those receiving immunosuppressive agents, deferoxamine therapy, or broad-spectrum antimicrobial drugs are at highest risk for zygomycosis. This review details the emergence and importance of zygomycosis in current clinical practice and its manifestations and management. The etiologic species, pathogenesis and risk factors for zygomycosis are reviewed and updated. The clinical spectrum of zygomycosis is now broader, and it can be difficult to distinguish between mucormycosis and enthomophthoramycosis, both of which can manifest as disease ranging from a superficial infection to an angioinvasive infection with high mortality. Finally, the three-part treatment strategy (antifungal drugs, surgery, control of underlying diseases) is reviewed. Lipid formulations of amphotericin B are the antifungal agents of choice for treatment of zygomycosis. A novel antifungal triazole, posaconazole, has been developed and may become approved for treatment of zygomycosis. The clinical experience with adjunctive treatments like colony-stimulating factors, interferon-gamma, and hyperbaric oxygen therapy is still limited.

Zygomycoses in patients with acute leukaemia

Zygomycoses are rare invasive mould infections which mainly occur in immunocompromised patients, especially during prolonged neutropenia. The high mortality rate is due to a high failure rate of both intravital diagnosis and treatment. Exact diagnosis requires microscopic examination and proof by culture. The treatment consists of amphotericin B and surgical debridement. We report four recent cases of zygomycosis among 89 patients with intensively treated acute leukaemia at our institution. Three cases were breakthrough infections since the patients were under voriconazole treatment prior to diagnosis of zygomycosis. Only one patient had premortal diagnosis (paranasal sinus infection) and showed clinical response with amphotericin B and surgical debridement. A review of the literature of these emerging fungal infections is given and is focused on patients with acute leukaemia. In addition, the importance of autopsy as a tool for quality control and epidemiological studies is pointed out.

Rhinoorbital and pulmonary zygomycosis post pulmonary aspergilloma in a patient with chronic lymphocytic leukaemia

A patient with an 18-year history of chronic lymphocytic leukaemia developed zygomycosis of the orbit, sinuses and nasal bones together with pulmonary fungal nodes due to Absidia corymbifera while on high dose steroids and four months after successful treatment of pulmonary aspergilloma with liposomal amphotericin B followed by oral voriconazole. He was treated successfully with extensive surgical debridement, intravenous liposomal amphotericin B and intravenous itraconazole.

The rising trend of invasive zygomycosis in patients with uncontrolled diabetes mellitus

Zygomycosis is an emerging infection worldwide. A study was conducted to understand its spectrum in the Indian scenario. All patients diagnosed for invasive zygomycosis at a tertiary care center in north India from 2000-2004, were retrospectively analyzed. A total of 178 cases (mean average of 35.6 cases/year) of zygomycosis were diagnosed. Rhino-orbito-cerebral type (54.5%) was the commonest presentation followed by cutaneous (14.6%), disseminated (9.0%), and gastrointestinal (8.4%) zygomycosis. Renal and pulmonary zygomycosis were seen in 6.7% patients each. Uncontrolled diabetes mellitus (in 73.6% of cases) was the significant risk factor in all types (Odds Ratio 1.5-8.0) except renal zygomycosis. Breach of skin was the risk factor in 46.2% patients with cutaneous zygomycosis. However, no risk factor could be detected in 11.8% patients. Antemortem diagnosis was possible in 83.7% cases. The commonest (61.5%) isolate was Rhizopus oryzae followed by Apophysomyces elegans in 27% patients. Combination of debridement surgery and amphotericin B therapy was significantly better in survival of the patients (P<0.005) than amphotericin B alone (79.6% vs. 51.7% survival). Thus, a rising trend of invasive zygomycosis was observed in patients with uncontrolled diabetes mellitus in India. Consistent diagnosis of renal zygomycosis in apparently healthy hosts and the emergence of A. elegans in India demand further study.

Zygomycosis: An emerging fungal infection

PURPOSE

The epidemiology, pathogenesis, clinical presentation and diagnosis, and management of zygomycosis are reviewed.

SUMMARY

The frequency of zygomycosis has been increasing over the past 10 years; infections have been identified in up to 6.8% of patients at autopsy. The most common route of transmission for Zygomycetes fungi is inhalation of spores from the environment. Patients at highest risk for infections caused by Mucorales fungi include those with profound immunosuppression or diabetes, intravenous drug abusers, premature infants, those receiving deferoxamine, and recipients of bone marrow transplants. Mucormycosis commonly presents as rhinocerebral or pulmonary disease; gastrointestinal presentations also occur. Clinical manifestations of invasive mucormycosis are tissue necrosis and subsequent thrombosis. Common features of pulmonary disease include fever, dyspnea, hemoptysis, and cavitation upon radiologic examination. The mainstays of treatment are control or reversal of the underlying disease or immunosuppression, antifungal therapy, and aggressive surgical debridement. Posaconazole, a new triazole antifungal, has been used successfully in a number of cases that did not respond to amphotericin B.

CONCLUSION

Zygomycosis appears to be on the rise in the United States. The standard treatment is a combination of amphotericin B therapy, surgical debridement, and reversal of the underlying disease or immunosuppression.

Hyperbaric oxygen as an adjunctive treatment for zygomycosis

Zygomycosis is a rare but emerging mycosis. Because of the sub-optimal efficacy of the standard antifungal treatment for this disease, hyperbaric oxygen (HBO) has been used occasionally as an adjunctive therapeutic modality. A review of 28 published cases of zygomycosis indicates that adjunctive HBO may be beneficial in diabetic patients (94% survival), whereas its benefit in the small group of patients with haematological malignancies or bone marrow transplants is doubtful (33% survival; p 0.02). Prolonged courses of HBO were associated with a higher survival (100% survival; p 0.003). Additional studies are required to assess the optimal timing and dose for HBO treatment.

Cutaneous zygomycosis following attempted radial artery cannulation

A 70-year-old man was seen in a hospital consultation for evaluation of cellulitis of the left arm. The patient had multiple medical problems, including advanced liver disease due to alcohol, diabetes mellitus, congestive heart failure, atrial fibrillation, chronic renal in sufficiency, and hypopituitarism requiring steroid replacement. Most recently, he was admitted to the intensive care unit, where he required intubation and mechanical ventilation support following respiratory failure secondary to pneumonia. At that time, an attempt was also made to place an arterial line in the left radial artery. The patient had multiple areas of ecchymosis on both arms. A large bulla was found on the lateral aspect of the left wrist several days after the attempted arterial line placement. Subsequently, the lesion drained serosanguineous fluid, and, during the next 2 days, it ulcerated with necrosis extending around the wrist and to the elbow. He was started on ampicillin/sulbactam and clindamycin for presumed necrotizing fasciitis. The surgical service performed a very limited debridement,which was partially limited by his coagulopathy from liver disease. The initial tissue culture was positive only for Enterococcus faecium. At the time of the consultation, his temperature was 95' F (35 degrees C), pulse 82 bpm, respirations 16 BPM, and blood pressure 101/56 mmHg. He was awake but not oriented or responsive. His cardiopulmonary exam was unremarkable. Abdominal exam disclosed ascites. His extremities were all grossly edematous with multiple ecchymoses. His left forearm had a circumferential area of ecchymosis and necrosis with macerated margins, sparing only the lateral ulnar epicondyle, and involving deeper structures of subcutaneous fat and muscle(Figures 1-2 showing evolution of the lesion in a period of 1 week). Small tissue clippings were taken from the edge of the lesion and placed on culture plates. By the next morning, the patient's tissue culture grew a mold, later identified as Rhizopus. Amphotericin B was initiated. Surgical intervention (wide debridement with potential conversion to amputation of the left arm) was considered to offer little benefit in view of the patient's multiple and severe comorbidities and his poor prognosis. Amphotericin B was then stopped; the patient died within a week from his multiple medical complications. The family refused an autopsy.

Emerging moulds: Fusarium, Scedosporium and Zygomycetes in transplant recipients

PURPOSE OF REVIEW

The incidence of non-Aspergillus mould infections in transplant recipients has increased over the past decade. This paper will review recent data regarding the epidemiology, clinical manifestations, treatment and the outcome of infections caused by Fusarium spp., Scedosporium spp. and the Zygomycetes in transplant recipients.

RECENT FINDINGS

Although the reasons for the increased incidence of non-Aspergillus mould infections in transplant recipients are not very clear, changes in transplant procedures, resulting in more severe immunosuppression, seem to play a major role, as suggested by recent epidemiologic data. Infections caused by these fungi have a tendency to be disseminated, and the prognosis is usually poor because the fungi are resistant to most of the available antifungal agents. New drugs, particularly the new azoles, may have a role in the treatment and prophylaxis of these infections, but the available data are still scant.

SUMMARY

The understanding of the changing epidemiology of fungal infections and their implications for the prognosis of transplant recipients are important to better evaluate the impact of new transplant procedures.

Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment

The class Zygomycetes is divided into two orders, Mucorales and Entomophthorales. These two orders produce dramatically different infections. Genera from the order Mucorales (Rhizopus, Mucor, Rhizomucor, Absidia, Apophysomyces, Cunninghamella and Saksenaea) cause an angioinvasive infection called mucormycosis. Mucormycosis presents with rhino-orbito-cerebral, pulmonary, disseminated, cutaneous, or gastrointestinal involvement. Immunocompromising states such as haematological malignancy, bone marrow or peripheral blood stem cell transplantation, neutropenia, solid organ transplantation, diabetes mellitus with or without ketoacidosis, corticosteroids, and deferoxamine therapy for iron overload predispose patients to infection. Mucormycosis in immunocompetent hosts is rare, and is often related to trauma. Mortality rates can approach 100% depending on the patient's underlying disease and form of mucormycosis. Early diagnosis, along with treatment of the underlying medical condition, surgery, and an amphotericin B product are needed for a successful outcome. Genera from the order Entomophthorales produce a chronic subcutaneous infection called entomophthoramycosis in immunocompetent patients. This infection occurs in tropical and subtropical climates. The genus Basidiobolus typically produces a chronic subcutaneous infection of the thigh, buttock, and/or trunk. Rarely, it has been reported to involve the gastrointestinal tract. The genus Conidiobolus causes a chronic infection of the nasal submucosa and subcutaneous tissue of the nose and face. This paper will review the clinical manifestations, diagnosis and treatment of mucormycosis and entomophthoramycosis.

Pediatric gastrointestinal basidiobolomycosis

Basidiobolomycosisis an unusual fungal infection that manifests in the skin and rarely involves other systems including the gastrointestinal tract. We retrospectively reviewed records of six pediatric patients (< or =14 years of age) diagnosed with gastrointestinal basidiobolomycosis from March 2000 to March 2002. Four patients came from the same region, suggesting environmental exposure. Basidiobolomycosis should be considered in the differential diagnosis in pediatric patients presenting with abdominal mass and eosinophilia.

Widespread cutaneous involvement by invasive Apophysomyces elegans in a gravid patient following trauma

Invasive infections in humans with organisms from the fungal subclass Zygomycetes are most commonly seen in immunocompromised and diabetic patients. Rarely, such fungal infections may be seen in immunocompetent, nondiabetic individuals. In these cases, cutaneous trauma with direct implantation of fungal organisms into the wound from soil contamination is the frequent scenario. We present the case of a 31-year-old gravid woman involved in a single-vehicle automobile accident who presented to our institution with severe head trauma. On admission, a small ecchymotic area on her right forearm was noted. The lesion eventually expanded and ulcerated. Culture and histologic examination of tissue from the site revealed fungal organisms consistent with Zygomycetes. Subsequent studies confirmed the fungal organism as Apophysomyces elegans. Antifungal therapy was initiated, and multiple debridements were performed. Amputation of the right arm above the elbow was eventually necessary, but aggressive surgical intervention and antifungal therapy were unsuccessful in preventing the spread of the infection. The patient died 2 weeks after admission from polymicrobial sepsis. This case illustrates the dangerously invasive nature of A elegans, even in immunocompetent individuals.

Zygomycotic infection of the neonatal upper extremity

Zygomycosis is a rare fungal infection that may present as a necrotizing soft tissue infection in the neonate. This report illustrates the typical presentation of a premature, infant with a rapidly progressive soft tissue necrotizing infection of his upper extremity at an intravenous site. Early diagnosis with tissue biopsy confirmed the diagnosis of Zygomycosis. Successful treatment required systemic amphotercin B and aggressive debridement requiring through-the-elbow amputation for survival.

Entomophthoromycosis in Maharaj Nakorn Chiang Mai Hospital

OBJECTIVE

To review documented entomophthoromycosis patients at Maharaj Nakorn Chiang Mai Hospital from 1985 to 2001.

MATERIAL AND METHOD

A retrospective review was performed at Maharaj Nakorn Chiang Mai Hospital from 1985 to 2001. Eight cases of entomophthoromycosis were found between 1988 and 1993, with five patients diagnosed as subcutaneous zygomycosis, I GI entomophthoromycosis and 2 rhinofacial zygomycosis.

RESULTS

The subcutaneous zygomycosis group was composed of 5 female patients, aged 7- 77 years. They presented with a painless subcutaneous mass, which was solitary or multiple and most commonly found on the extremities. The duration of disease was between 3 months to 5 years. The cultures grew Basidiobolus ranarum. A case of GI entomophthoromycosis was seen in a 34 year old man, who presented with dyspepsia, multiple intraabodminal masses and peritonitis. Two cases of conidiobolomycosis (rhinofacial zygomycosis) were seen. These two patients were male, 26 and 39 years old, and they presented with unilateral nasal obstruction from a mass at the inferior turbinate. The cultures grew Conidiobolus coronatus.

CONCLUSION

Entomophthoromycosis in the northern part of Thailand is rare. The disease should be differentially diagnosed by a chronic painless tumor. The patients in this review responded very well to the recommended therapy.

[Rhino-orbital zygomycosis]

Zygomycosis is rare but highly invasive fungal infection, with high mortality rate. A 67 years old diabetic man was presented with rhino-ocular form of the disease. Fungal elements invaded the skin and subutaneous facial tissue, with involvement of the nose, paranasal sinuses and orbit. The portal of entry of fungus was through paranasal sinuses, after the tooth extraction. Various clinical manifestations were presented: headache, facial swelling, tenderness over the involved sinuses, unilateral orbital cellulitis with proptosis, facial and orbital pain, black nasal discharge, decreased visual acuity, blindness. Patient was treated surgically and by liposomal amphotericin B. He underwent maxillectomy, ethmoidectomy and sphenoidectomy and orbital exenteration because of the dissemination of the disease into the orbit. The specific diagnosis of the infection was established upon the microscopic demonstration of casual agent in the debridement tissue. Early diagnosis was important in this highly fatal disease. Aggressive surgical debridement, therapy with amphotericin B and correction of underlying metabolic acidosis must be performed. The successful medical therapy in this patient suggests that lipid formulation of amphotericin B should be given, because this antifungal agent performed the best control of the infection with the minimal adverse effects.

Ten years' experience in zygomycosis at a tertiary care centre in India

OBJECTIVE

To define the spectrum of zygomycosis due to mucorales in an Indian scenario.

METHODS

One-hundred and twenty-nine patients with zygomycosis due to mucorales diagnosed at the Postgraduate Institute of Medical Education and Research, Chandigarh, India during 1990-99, were retrospectively analysed regarding the sites of involvement, underlying disease, species of fungi isolated and outcome of therapy.

RESULTS

Higher prevalence rate (19.4%) was observed in 1999. Rhino-orbito-cerebral type (44.2%) was the commonest presentation followed by cutaneous (15.5%) and renal (14.0%) involvement. Disseminated zygomycosis was seen in 11.6% patients. Pulmonary and gastrointestinal zygomycosis were diagnosed in 10.1% and 4.7% patients, respectively. Uncontrolled diabetes mellitus (in 50% of cases) was the significant risk factor in rhino-orbito-cerebral type [odds ratio (OR), 9.3; P<or=0.001) and breach of skin (in 40% cases) in cutaneous zygomycosis (OR, 6.9; P<or=0.01). However, a considerable number of 22 (22.9%) patients were apparently healthy hosts in this series. Forty-five patients (34.9%) of this series were diagnosed only at post-mortem. Among 47 patients where culture was attempted, mucorales were isolated from 25 patients with Rhizopus arrhizus (11 patients) and Apophysomyces elegans (eight patients) as the predominant isolates. Adequate therapy could be provided in 33 patients. A combination of aggressive surgical debridement of necrotic tissue and amphotericin-B was found to be the best treatment protocol as 81.3% patients treated with surgical debridement and amphotericin-B were cured, compared with 46.7% patients treated with amphotericin-B alone.

CONCLUSION

The study highlights the importance of increased awareness for early diagnosis of zygomycosis and aggressive management. The large number of cases in apparently healthy hosts and increased isolation of A. elegans in the present series are important characteristics of this disease in India and requires further evaluation.

A review of zygomycosis due to Basidiobolus ranarum

Zygomycosis due to Basidiobolus ranarum (entomophthoromycosis basidiobolae, subcutaneous zygomycosis, subcutaneous phycomycosis, basidiobolomycosis) is a granulomatous infection of the skin and subcutaneous tissues characterized by the formation of fluctuant firm and non-tender swellings, generally on the extremities, trunk and rarely other parts of the body. The causative agent is common in soil, decaying vegetable matter, and the gastrointestinal tracts of amphibians, reptiles, fish and bats. It is presumed that infection is acquired through exposure to B. ranarum following minor trauma to skin or insect bites. The disease usually occurs in children, less often in adolescents and rarely in adults. Males are much more frequently affected than females. Laboratory diagnosis is based on histopathology and culture. The typical histopathological feature is the presence of thin-walled, broad often aseptate hyphae or hyphal fragments with an eosinophilic sheath, frequently phagocytized within giant cells. Basidiobolus ranarum is known to produce several enzymes, e.g. lipase and protease that probably play roles in the pathogenesis of infections caused by this mould. An immunological test has been developed for specific diagnosis of the disease. Though potassium iodide (KI) has been the traditional drug employed in the treatment of infections by B. ranarum, several other drugs, viz amphotericin B, cotrimoxazole, ketoconazole, itraconazole and fluconazole have been successfully tried.

Rhinocerebral zygomycosis following bone marrow transplantation in chronic myelogenous leukaemia. Report of a case and review of the literature

We report on a man suffering from chronic myelogenous leukaemia treated by allogeneic bone marrow transplantation who, in the late post-transplantation phase, developed a hyperacute fatal invasive rhinocerebral zygomycosis. The origin of the ascending infection was the sinus sphenoidalis from which fungal hyphae spread to the central nervous system via the skull and the dura mater. The first symptoms of this severe infection were cerebral convulsions and a bilateral total amaurosis. The isolation of the pathogen from post mortem tissue was not successful. The present case is compared with previous reports of zygomycoses after bone marrow transplantation.