[Pulmonary Mucormycosis with Reversed Halo Sign on Computed Tomography of Patient with Leukemia]

The patient was a male in his 60s, who had undergone bone marrow transplantation because of lymphoblastic leukemia. He suffered from chest pain two weeks after the transplantation. A chest computed tomography(CT) showed reversed halo sign( RHS) in the right upper lobe of the lung. A bronchoscopic lung biopsy revealed mycelia, and the patient was diagnosed with pulmonary mucormycosis. Although antifungal drugs were administered, no significant improvements were observed. A right upper lobectomy of the lung was successfully performed, and no postoperative complications occurred. Pathological examination found nodular lesions with extensive necrotic foci inside, and inflammatory granulation tissue and mucormycosis with hyphae (+) were found through Grocott staining. RHS in leukemia patients with neutropenia is specific to pulmonary mucormycosis. Pulmonary mucormycosis is a life-threatening disease, and urgent treatment intervention including surgical treatment is advisable.

Mucormycosis in a patient with acute myeloblastic leukemia following liver transplantation for Wilson's disease

A case is presented of mucormycosis in a patient with acute myeloblastic leukemia following liver transplantation for Wilson's disease. A 58-year-old female was admitted to the Department of Haematology with deterioration of her general condition, loss of appetite, tiredness and difficulty with mental contact for a few days. Blood and urine cultures for bacteria and fungus, galactomannan antigen were negative. Whole body computed tomography demonstrated bilateral hilar lymphadenopathy with necrotic lesions: splenomegaly with a hypodensive lesion 13 × 20 × 19 mm and lower pulmonary infiltrates suggested fungal etiology. Magnetic resonance imaging of the brain showed thickened meninges. Finally, mucormycosis was diagnosed. Treatment with amphotericin B lipid complex was started, resulting in an partial improvement of the general condition and decreased level of inflammatory markers. However, the patient's condition continued to deteriorate, with sepsis etiology Escherichia coli, and despite the intensive managements she eventually died.

Mucormycosis creeping along the nerves in an immunocompetent individual

Mucormycosis is a rare opportunistic fungal infection, often life-threatening. We report an unusual case of rhinocerebral mucormycosis in an immunocompetent patient. A 23-year-old male presented with headache, speech disturbance and hearing difficulty for 4 weeks. Magnetic resonance imaging (MRI) revealed right cerebellar abscess and enhancing soft tissue in the nasal cavity, extending to cranial and infratemporal fossae. Computed tomography (CT) revealed the widening of foramen rotundum and sclerosis involving the sphenoid and ethmoid sinuses. MR Spectroscopy revealed multiple peaks between 3.6 and 3.8 parts per million (ppm) which could represent trehalose. Nasal mucosa scrapings confirmed mucormycosis. Suspicion of a fungal infection needs to be considered even in the absence of immunocompromised status.

Mucorales-Specific T Cells in Patients with Hematologic Malignancies

Background

Invasive mucormycosis (IM) is an emerging life-threatening fungal infection. It is difficult to obtain a definite diagnosis and to initiate timely intervention. Mucorales-specific T cells occur during the course of IM and are involved in the clearance of the infection. We have evaluated the feasibility of detecting Mucorales-specific T cells in hematological patients at risk for IM, and have correlated the detection of such cells with the clinical conditions of the patients.

Methods and Findings

By using an enzyme linked immunospot assay, the presence of Mucorales-specific T cells in peripheral blood (PB) samples has been investigated at three time points during high-dose chemotherapy for hematologic malignancies. Mucorales-specific T cells producing interferon-γ, interleukin-10 and interleukin-4 were analysed in order to detect a correlation between the immune response and the clinical picture. Twenty-one (10.3%) of 204 patients, accounting for 32 (5.3%) of 598 PB samples, tested positive for Mucorales-specific T cells. Two groups could be identified. Group 1, including 15 patients without signs or symptoms of invasive fungal diseases (IFD), showed a predominance of Mucorales-specific T cells producing interferon-gamma. Group 2 included 6 patients with a clinical picture consistent with invasive fungal disease (IFD): 2 cases of proven IM and 4 cases of possible IFD. The proven patients had significantly higher number of Mucorales-specific T cells producing interleukin-10 and interleukin-4 and higher rates of positive samples by using derived diagnostic cut-offs when compared with the 15 patients without IFD.

Conclusions

Mucorales-specific T cells can be detected and monitored in patients with hematologic malignancies at risk for IM. Mucorales-specific T cells polarized to the production of T helper type 2 cytokines are associated with proven IM and may be evaluated as a surrogate diagnostic marker for IM.

Mucormycosis (Mucor fungus ball) of the maxillary sinus

A fungus ball is an extramucosal fungal proliferation that completely fills one or more paranasal sinuses and usually occurs as a unilateral infection. It is mainly caused by Aspergillus spp in an immunocompetent host, but some cases of paranasal fungal balls reportedly have been caused by Mucor spp. A Mucor fungus ball is usually found in the maxillary sinus and/or the sphenoid sinus and may be black in color. Patients with mucormycosis, or a Mucor fungal ball infection, usually present with facial pain or headache. On computed tomography, there are no pathognomonic findings that are conclusive for a diagnosis of mucormycosis. In this article we report a case of mucormycosis in a 56-year-old woman and provide a comprehensive review of the literature on the "Mucor fungus ball." To the best of our knowledge, 5 case reports (8 patients) have been published in which the fungus ball was thought to be caused by Mucor spp.

[Non-obstructive hydrocephalus internus with a rare pathogenesis--mucormycosis]

The case of a 9-year-old boy is presented in this article who developed a rare fungal infection of central nervous system. The histopathologic examination has revealed mucormycosis. The diagnosis wasn't confirmed microbiologically as the culture and PCR were negativ. After the iv administered Amphotericin B lipid complex the MR images of the brain have improved. The mucormycosis classically develops in immunodeficient patients and presents an acute, fulminant, mostly lethal infection. This case is very unusual, because the chronic, isolated CNS mucormycosis has slowly developed in immuncompetent patient and only one symptom was the long existing headache. The aim of this paper is reporting the case history and to find out the possible way of infection.

Cardiac mucormycosis with T-cell immunodeficiency

We present a case of a 2 year old apparently healthy child who presented with fever and mass on the mitral valve. Excision histopathology of the mass revealed mucormycosis. After 4 months, she had CNS embolisation with recurrence of cardiac lesion when investigations revealed associated T-cell immunodeficiency.

[Imaging of fungal infection in diabetic patients]

Diabetes mellitus is an important risk factor for infections caused by fungi. Candidiasis is the most frequent fungal infection in diabetic patients, followed by aspergillosis, cryptococcosis, and mucormycosis. Fungal infection is a serious cause of morbidity and mortality in immunocompromised hosts. Diagnostic imaging plays an important role in the early diagnosis and treatment for these infections, especially for the pulmonary infection. Although imaging findings of pulmonary fungal infection are various, ground-glass opacity surrounding nodules or masses called "CT halo sign" is a relatively characteristic finding. In this review, we discuss the imaging finding of fungal infection particularly focusing on the pulmonary lesions.

Angioinvasive pulmonary mucormycosis presenting as multiple bilateral pulmonary nodules in a patient without obvious predisposing factors

Pulmonary mucormycosis is a rare, frequently fatal, fungal infection. It is usually seen in the presence of various immunocompromised states, such as diabetes mellitus, haematological malignancy or renal transplantation. In the absence of underlying predisposing conditions, presentation with infiltrates, consolidation, cavitation and mass lesion have been reported. We describe a 50-year-old man who presented with cough and chest pain for six months. Chest radiograph and computed tomography showed bilateral multiple pulmonary nodules. Surgical lung biopsy revealed angioinvasive mucormycosis. He had complete recovery with amphotericin therapy.

Imagerie des formes viscérales graves de la mucormycose chez 5 patients immunodéprimés

OBJECTIVES

Show the contribution of imaging to the diagnosis and follow-up of serious mucormycosis in immunodepressed patients.

MATERIALS AND METHODS

Retrospective analysis of the 5-year radiological data in serious forms of mucormycosis occurring in patients with bone marrow allografts who are in refractory chronic graft-versus-host disease after bone marrow transplantation from 2002 to 2005. The positive diagnosis was bacteriologically and pathologically positive in all cases.

RESULTS

This study involved three patients with isolated pulmonary involvement and two cases of disseminated mucormycosis. Areas of pulmonary condensations were found in all cases, one of whom had a low-attenuation zone and parenchymal nodules. The kidney, liver, and spleen lesions were clearly limited, hypoechogenic, hypodense, and homogenous with no peripheral contrast material uptake. There was thyroid involvement in the form of hypoechogenic nodules. Rapid growth of the lesions was observed on follow-up CT (n=3) and despite surgical treatment (n=2) and intensive medical management, all cases ended in death.

CONCLUSION

Mucormycosis is an integral part of the differential diagnosis of infectious syndromes in immunodepressed patients during the period after bone marrow transplantation. Imaging can assist in the diagnosis but pathological confirmation remains indispensable.

Successful Treatment of Mucormycosis Endocarditis Complicated by Pulmonary Involvement

Cardiac mucormycosis is an exceedingly rare condition. This case report describes mucormycosis endocarditis in an immunocompromised patient with ulcerative colitis. His condition was further complicated by multiple septic emboli to the lungs. His management included surgical excision of the right atrial endocarditic vegetation and antifungal treatment with high-dose liposomal amphotericin B.

Oral mucormycosis in children with leukemia: report of 2 cases

Mucormycosis is a rare acute opportunistic infection caused by a saprophytic fungus, which belongs to the order Mucorales. This report describes intraoral mucormycosis in 2 children with acute leukemia who were undergoing chemotherapy and had febrile neutropenia. A 7-year-old boy with acute myeloid leukemia and a 9-year-old boy with acute lymphoblastic leukemia were referred to the Department of Pediatric Dentistry at Cukurova University for their intraoral soft tissue lesions, which were diagnosed as mucormycosis by histologic examination. While, for the first case, the lesion was debrided under general anesthesia and medical antifungal therapy was performed, only medical management was done, without any debridement, for the second case. Early recognition of mucormycosis is necessary to limit the spread of infection, which can lead to high morbidity and mortality. Therefore, health practitioners should be familiar with the signs and symptoms of the disease.

Pulmonary multinodular mucormycosis in type 1 diabetic patient with diabetic ketoacidosis

We report a case of pulmonary multinodular mucormycosis in a Type 1 diabetic patient with diabetic ketoacidosis. He had a history of 20-pack-year tobacco use. The initial chest roentgenogram and thorax tomography (after the treatment of diabetic ketoacidosis) revealed multiple nodular lesions with cavitation in the upper lobes of pulmonary parenchyma. Resection of three nodular lesion demonstrated cheesy necrotic mass in the cavitating lesions. The diagnosis of pulmonary multinodular mucormycosis was made depending on the histopathologic examination yielding nonseptated right angle branching-shaped hyphae typical of mucormycosis. The patient was started on liposomal amphotericin B and discharged at the sixth week of therapy with a scheduled therapy of amphotericin B. When he came back after 33 months, he was metabolically unregulated under the insulin therapy. He confessed that he had been smoking heroin besides tobacco for the last 5 years. A new thorax computerized tomography showed that pulmonary nodules were slightly regressed but not resolved.

Auricular mucormycosis: a case report

Mucormycosis is a rare, saprophytic, invasive, and fulminant fungal disease. It occurs in immunocompromised patients such as those with diabetes mellitus or blood dyscrasia, or in patients under immunosuppressive therapy. A 17-year-old female patient with diabetic ketoacidosis presented with a black-colored lesion in the auricle and external ear canal. Physical examination showed necrosis of the auricle, external ear canal, and neighboring skin. She also had facial paralysis. Debridement of the necrotic tissues was performed and the samples were submitted for microbiologic and histopathologic examination, which showed nonseptate hyphae. Postoperatively, systemic amphotericin B was empirically administered. The patient died on the seventh day.

Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation

Disseminated mucormycosis is a rare, mostly fatal infectious complication in immunocompromised haematological patients. The purpose of our study was to describe the multiorgan manifestations of disseminated mucormycosis documented at CT and MRI in four patients and correlate these with the pathological findings and patient outcome. Irrespective of the site of infection, infarction or haemorrhage are the constant features of invasive mycosis. Identification of one or both of these two major imaging findings in immunocompromised patients should be regarded as an indicator of possible infection by angiotropic fungi, including the genre Mucorales.

Periorbital zygomycosis (mucormycosis) treated with posaconazole

PURPOSE

To report on the successful treatment of periorbital zygomycosis (mucormycosis) with posaconazole, a broad-spectrum oral antifungal available for compassionate use.

DESIGN

Interventional case report.

METHODS

Review of a medical record.

RESULTS

A 22-year-old male undergoing induction chemotherapy for acute lymphoblastic leukemia presented with periorbital cellulitis attributable to Rhizopus. The patient was initially treated with liposomal amphotericin B, surgical debridement, and reversal of immune compromise. The patient was switched to posaconazole because of amphotericin side effects and lack of improvement. He took posaconazole for five months while undergoing additional cycles of chemotherapy. Despite recurrent profound neutropenia, the periorbital infection resolved, he tolerated reconstructive procedures, and he did not develop orbital invasion. His Rhizopus isolate was highly susceptible to posaconazole in vitro.

CONCLUSIONS

Drug toxicities can limit the use of amphotericin in some patients with zygomycosis. Posaconazole shows promise as an alternative antifungal agent in the treatment of periorbital zygomycosis.

Successful Treatment of Rhinomaxillary Form of Mucormycosis Infection After Liver Transplantation: A Case Report

Mucormycosis is a rare opportunistic infection, usually associated with immunocompromised states. Several conditions such as hematologic malignancy (leukemia, lymphoma, myeloma), solid organ transplantation, diabetes mellitus, corticosteroid therapy, or chemotherapy predispose patients to infection. The aim of this study was to present a single case of mucor infection after 900 consecutive liver transplantations. Rhinomaxillary mucormycosis must be suspected in a transplant recipient showing fever, maxillary swelling, and edema. This condition can be successfully treated with early diagnosis and a combination of aggressive surgery and antifungal therapy.

Utility of computed tomography (CT) and of fine needle aspiration biopsy (FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients

PURPOSE

The purpose of this study was to evaluate the sensitivity of percutaneous computed tomography (CT)-guided lung biopsy in the early diagnosis of fungal pulmonary infections.

MATERIALS AND METHODS

Between 1997 and 2003, 18 haematologically immunodeficient patients with suspected filamentous fungi infection and negative bronchoalveolar lavage (BAL) underwent percutaneous pulmonary biopsy to diagnose the nature of the infection. In all cases, infection developed during the post-chemotherapy bone marrow aplasia period.

RESULTS

Thirteen out of 18 patients had histologic findings positive for fungal infection: 8 Aspergillus and 5 Mucor. In 3 cases, biopsy was not specific, and in one case, the tissue sample was inadequate for a diagnosis; however, clinical course and response to drugs were compatible with fungal infection. In one patient, biopsy was positive for bronchoalveolar carcinoma. The sensitivity of percutaneous CT-guided biopsy was 80% and its positive predictive value was 100%. We only had one pneumothorax as a complication.

CONCLUSIONS

Percutaneous CT-guided lung biopsy is an easy, safe and reliable procedure to obtain diagnostic material. Histological discrimination between Aspergillus and Mucor is important in order to plan the correct therapeutic protocols, as Mucor is usually resistant to azoles.

L’imagerie dans la mucormycose rhinocérébrale

PURPOSE

Rhinocerebal mucormycosis is a rare life threatening fungal infection observed in immunocompromised patients. We report six cases of patients with rhinocerebral mucormycosis confirmed histologically. Our study confirms the necessity of early diagnosis when clinical and CT findings are suggestive.

MATERIALS AND METHODS

This is a retrospective study including 6 diabetic patients (3 women and 3 men) aged from 28 and 63 years. Five patients had ethmoiditis evolving for a few days (3 to 5 days), and one patient was in an ketoacidotic coma and had a severe infectious syndrome with purulent rhinorrhea evolving for 4 days. All of our patients underwent computed tomography (CT) scan of the paranasal sinuses. MRI was performed in two patients with neurological findings.

RESULTS

Unilateral ethmoido-maxillary sinusitis was noted in 5 cases. Only one case of pansinusitis was found. All patients presented orbital involvement. Cerebral involvement was noted in 4 cases (cerebral venous thrombosis: 2 cases; abscess: 2 cases; cerebral ischemia: 2 cases). The diagnosis of mucormycosis was based on endonasal biopsy. When available, MRI allowed a more precise evaluation of the orbital and cerebral extension.

CONCLUSION

Mucormycosis is an opportunist mycosis due to mucoralis fungus. It is very invasive with a highly aggressive potential in diabetic or immunocompromised patients. Imaging study particularly CT scan, plays an important role in diagnosis especially to evaluate cerebral extension.