[Computed tomographic appearance of pulmonary mucormycosis]

AIM

Analysis of the morphological characteristics of pulmonary mucormycosis using computed tomography (CT).

MATERIAL AND METHODS

Prospective analysis of CT studies in 9 patients out of 19 patients with proven pulmonary mucormycosis.

RESULTS

Pulmonary mucormycosis was most frequently found in the upper lobe bilaterally (51% of all nodules). In 22% of the manifestations, the morphological criterion of a "bird's nest" could be verified in CT, in 37% central necrotic areas were detected. In 37% an open bronchus was diagnosed, in 6% we observed bronchiectases. 43% of all nodules presented with a halo sign. In three patients we found pleural effusions, enlarged mediastinal lymph nodes were diagnosed in one patient.

CONCLUSION

Computed tomography allows an improved diagnosis and therapeutic follow-up in patients suffering from pulmonary mucormycosis.

Hepatic and small bowel mucormycosis after chemotherapy in a patient with acute lymphocytic leukemia

Mucormycosis is a rare but invasive opportunistic fungal infection with increased frequency during chemotherapy-induced neutropenia. The clinical infections due to Mucor include rhinocerebral, pulmonary, cutaneous, gastrointestinal and disseminated diseases. The first two are the most common diseases and all entities are associated with a high mortality rate. Still hepatic involvement of Mucor is rarely reported. We experienced a case of hepatic and small bowel mucormycosis in a 56-year-old woman after induction chemotherapy for B-cell acute lymphocytic leukemia. Initial symptoms were a high fever unresponsive to broad spectrum antibiotics and pain in the left lower abdominal quadrant. It was followed by septic shock, deterioration of icterus and progressively elevated transaminase. An abdominal CT demonstrated multiple hypodense lesions with distinct margins in both lobes of liver and pericolic infiltration at small bowel and ascending colon. Diagnosis was confirmed by biopsy of the liver. The histopathology of the liver showed hyphae with the right-angle branching, typical of mucormycosis. The patient was managed with amphotericin B and operative correction of the perforated part of the small bowel was performed. However, the patient expired due to progressive hepatic failure despite corrective surgery and long-term amphotericin B therapy.

Successful treatment of prosthetic aortic valve mucormycosis

Mucor endocarditis after cardiovascular surgery is rare and usually fatal. We report the first known case of prosthetic aortic valve mucormycosis in a patient without predisposing risk factors who was successfully treated using a combination of early antifungal drug therapy and surgical removal of infected material.

Bronchial mucormycosis with progressive air trapping

A previously healthy 70-year-old woman developed fever, cough, and exertional dyspnea. Her symptoms progressed over a 2-month period despite treatment by her primary care physician with 2 courses of oral antibiotics and the addition of prednisone. Hypoxemia and the finding of hyperglycemia with mild ketoacidosis led to hospital admission. Serial chest radiographs demonstrated diffuse heterogeneous pulmonary opacities and progressive air trapping in the right lower lobe. Fiberoptic bronchoscopy revealed a deep penetrating ulcer with exposed bronchial cartilage of the bronchus intermedius and dynamic airway obstruction with complete closure during expiration. Biopsy of the ulcer revealed Rhizopus arrhizus. Respiratory failure stabilized with the patient on conventional mechanical ventilation and receiving amphotericin B. Before surgery could be performed, Pseudomonas aeruginosa pneumonia and septic shock developed, and the patient died.

Mucormycosis of the central airways: CT findings in three patients

Computed tomographic (CT) findings are described in three diabetic patients with central airways mucormycosis. The CT findings of the tracheobronchial mucormycosis include enhancing areas of mural thickening (n = 3), luminal narrowing (n = 3), intramural air (n = 3), low-attenuation nonenhancing bronchial wall thickening (n = 2), and bronchonodal fistula formation (n = 1). These CT features in a diabetic patient should raise a high index of suspicion for tracheobronchial mucormycosis, particularly when typical radiographic features of pulmonary tuberculosis are absent.

[Treatment review in rhinocerebral mucormycosis]

The rhinocerebral mucormycosis is the more common form produced by Rhizopus, a genus of fungi. It's a serious infective disease with high mortality, that needs a precocious medical treatment. Amphotericin B is the choice medical treatment, but liposomal amphotericine B in recent years is a better drug, due to minor renal toxicity and greater tisular diffusion. Even can not to treat all affected areas it's necessary an extensive surgical treatment according to individual characteristics and disease evolution. A 56-year-old man with rhinocerebral mucormycosis, caused by Rhizopus, who was treated with liposomal-amphotericin B and extensive rhino-orbital surgery is presented.

Successful medical management of isolated renal zygomycosis: case report and review

We describe the medical management of isolated renal zygomycosis in an adult patient with AIDS during chemotherapy for AIDS-related lymphoma. After initial presentation during the first cycle of chemotherapy, the infection was contained within the kidney following recovery of the neutrophil count without medical or surgical intervention. Since he was not considered to be a candidate for nephrectomy, his infection was treated with amphotericin B lipid complex during subsequent chemotherapy. Neutropenia was minimized by the addition of cytokine support therapy with granulocyte colony-stimulating factor and reduced doses of chemotherapy. Following this strategy, his lymphoma completely resolved, and renal zygomycosis was controlled. At the time of this writing, he had been in complete remission for 18 months without evidence of progressive fungal infection. This report and our literature review indicate that isolated renal zygomycosis can be associated with a favorable prognosis, occurs with greatest frequency in patients with AIDS, is associated with parenteral access, and may be managed by medical therapy alone.

[Pulmonary mucormycosis in a leukemia patient. Diagnostic and therapeutic difficulties]

The observation of pulmonary mucormycosis occurring in a patient presenting with aplasia induced therapeutically during treatment for acute myeloblastic leukaemia, has led to a review of the characteristics of this rare opportunistic fungal infection: it occurs in a particular condition; the clinical manifestations are characterised by the thrombotic character and the rapidly necrosing nature of the histological lesions; the diagnosis is usually very difficult to make and is linked to the rarity of the pathology and the frequently negative mycological specimens apart from tissue biopsies; the value of a medicosurgical therapeutic strategy on which the prognosis of the infection depends.

Mucor pyelonephritis. Report of a case diagnosed by urine cytology, with diagnostic considerations in the workup of funguria

BACKGROUND

Isolated renal mucormycosis is an uncommon kidney infection affecting patients with underlying systemic diseases and intravenous (IV) drug abuse. We report a unique case in the cytologic literature in which urine cytology provided insight into the diagnosis, renal mucormycosis.

CASE

The patient, a diabetic and IV drug abuser, presented with complaints of left flank pain, fever and dysuria. All urine cultures were negative. A computed tomography (CT) scan showed changes consistent with left acute pyelonephritis, and the patient was treated for a presumed diagnosis of bacterial pyelonephritis. Late in the hospital stay, the cytology laboratory diagnosed Mucor in a single urine specimen, but the patient had already been discharged. The patient was never treated for funguria, only to present again with left flank pain 13 months later. An abdominopelvic CT scan showed progression to left chronic pyelonephritis. The patient, however, left the hospital against medical advice before any further workup could be completed.

CONCLUSION

Renal mucormycosis should be considered part of the differential diagnosis in patients with underlying diseases or IV drug abuse who present with symptoms of acute pyelonephritis. The differential diagnosis of Mucor funguria should also include fungal ball in the renal pelvis or urinary bladder and fungal cystitis.

[Disseminated mucormycosis. A rare case in pediatric intensive care]

A rare case of disseminated mucormycosis occurred in a 3-year-old boy suffering from a 4th degree neuroblastoma, treated with chemiotherapy and broad-spectrum antibiotics is reported. The child was admitted in the pediatric intensive care unit after surgical debridement of a wide part of the bowel showing necrosis and vessel thrombosis. After the histological diagnosis of mucormycosis in the gastrointestinal tract and the echographic detection of multiple mycotic localizations in the liver and kidneys, a treatment with high-dose amphotericin B was carried out. At the same time, the occurrence of anaerobiosis and/or acidosis as well as hyperglycemia was avoided in order to prevent the hyphae growth. This therapeutic strategy has been successful in preventing the infection spread, so that after 10 months from the discharge from the intensive care unit the child is in good health and the liver and kidney lesions are unchanged.

Pulmonary mucormycosis: radiologic findings in 32 cases

OBJECTIVE

The purpose of this study was to characterize the radiologic manifestations of pulmonary mucormycosis with clinical and pathologic correlation.

MATERIALS AND METHODS

Clinical records, pathology reports, chest radiographs, and CT scans of 32 cases of pathologically proven pulmonary mucormycosis were retrospectively reviewed.

RESULTS

The study group included 20 males and 12 females with a mean age of 47 years old. Clinical data were available for 29 patients. Signs and symptoms included fever (n = 23), cough (n = 21), bloody sputum (n = 9), dyspnea (n = 7), and chest pain (n = 6). Four patients were asymptomatic. Most patients were either immunocompromised (n = 20) or had diabetes mellitus (n = 9). Sputum or bronchoalveolar lavage cultures showed no growth in 17 of 18 cases. Diagnoses were confirmed at surgery or autopsy in all cases. Abnormalities seen on chest radiographs included lobar (n = 15) or multilobar (n = 6) consolidation, solitary (n = 7) or multiple (n = 1) masses, and solitary (n = 3) or multiple (n = 2) nodules. Cavitation was seen on chest radiographs in 13 patients, and intracavitary masses were seen in four. Associated radiographic findings included hilar (n = 3) or mediastinal (n = 3) adenopathy and unilateral (n = 6) or bilateral (n = 3) pleural effusion. CT in 19 patients revealed these significant additional findings: splenic (n = 1) or renal (n = 1) involvement, bronchial occlusion (n = 1), extrapulmonary invasion (n = 1), and pulmonary artery pseudoaneurysm (n = 1).

CONCLUSION

In our study, pulmonary mucormycosis typically was manifested in immunocompromised or diabetic patients by consolidation on chest radiographs; cavitation was seen in 40% of patients. CT revealed significant unsuspected abnormalities in 26% of patients. Definitive diagnosis required pathologic demonstration of the organism in affected tissue because cultures from our patients rarely showed growth.

Rhinocerebral and systemic mucormycosis. Clinical experience with 36 cases

We analysed retrospectively our clinical experience with 36 cases of mucormycosis. They were seen during the last 15 years. The diagnosis suspected on clinical grounds, was confirmed in 31 cases by finding the hyphae in hematoxylin-eosin stained material obtained from aspirated or tissue biopsy or by isolation of the fungus in culture. Rhinocerebral mucormycosis was diagnosed in 22 patients. Diabetes was the underlying disorder in 20 cases, kidney failure in one and myelodysplastic syndrome in one. Nine had stable and 11 unstable diabetes (ketoacidosis in 10 and hyperosmolar coma in 1). The earliest sign was facial edema, followed by proptosis, chemosis and extraocular muscle paresis. They were treated by extensive surgical debridement, insulin and antifungal drugs with 69% of survival rate. The disseminated mucormycosis was diagnosed at the autopsy in 5 cases, acute leukemia was the underlying disease in 2 of them. Pulmonary mucormycosis was diagnosed in 2 cases, cutaneous form in 2, sinuorbital form in 4 and brain abscess in one patient. Eight of these 9 cases survived after therapy. We emphasize the importance of an early diagnosis. This can only be made in the presence of a typical clinical setting confirmed by finding the hyphae in tissue or culture. Antifungal drugs along with treatment of the underlying disorder and aggressive surgical debridement must follow.

A case report of novel roentgenographic finding in pulmonary zygomycosis: thickening of the posterior tracheal band

Zygomycosis (Mucormycosis) has been reported to involve most of the organ systems in man, although pulmonary zygomycosis with mediastinum invasion in rare and only few cases were reported in the literature previously. The roentgenographic findings of pulmonary zygomycosis have been well-discussed. However, the lateral view of chest radiograph has never been described. We report a patient with diabetes mellitus who had pulmonary zygomycosis with mediastinal involvement, presenting as thickening of posterior tracheal band (PTB, 6mm in width). Amphotericin B therapy effectively reduced it to return to normal width.

Nonsurgical cure of isolated cerebral mucormycosis in an intravenous drug user

The case of a 30-year-old, female, HIV-positive intravenous drug user who suffered from isolated cerebral mucormycosis is reported. Treatment with amphotericin B at an accumulative dose of 5.5 grams led to significant recovery, and there was no recurrence of disease over a follow-up period of six months. Patients with isolated cerebral mucormycosis in whom surgery would be a high-risk or impossible procedure could be managed medically with prolonged courses of intravenous amphotericin B.

Mucormycosis of the sphenoid sinus in an otherwise healthy patient. Case report and literature review

Paranasal and rhinocerebral mucormycosis refers to uncommon opportunistic fungal infections, reported to occur especially in association with diabetic acidosis (the most common), immunosuppressive therapy, malignancy, or other chronic debilitating disorders. However, patients who have no underlying disease have occasionally been affected. According to the literature reviewed, only 13 well-documented cases without any predisposing factor have been previously reported. We describe a unique case of sphenoidal mucormycosis in an otherwise healthy individual, and the first patient to present with headache as the only symptom. We emphasize the importance of a high index of suspicion for early diagnosis and prompt management.

[Systemic mucormycosis in dialysis: computed tomography picture and histologic lesions]

Mucormycosis (zygomycosis) is an uncommon mycosis which can be contracted from the environment and which is responsible for rhino-orbital, pulmonary, gastrointestinal, cerebral or disseminated infections. Severe immunodepression, such as that caused by leukemia, lymphomata and organ graft, or treatment by desferrioxamine, may predispose to pulmonary and systemic forms. In the present work the authors describe a case of systemic mucormycosis, with unfavourable outcome, which arose in a pediatric peritoneal dialysis patient, then transferred to hemodialysis, without evident predisposing factors. In particular they refer to the CAT reports and to lymphonodal and peritoneal histological lesions which allowed them to attain the diagnosis.

Mucormycosis after bone marrow transplantation: report of four cases in thalassemia and review of the literature

We report four cases of mucormycosis that occurred among 711 patients who underwent BMT for thalassemia, and review 18 additional cases among BMT recipients that were reported in the English-language literature. All these patients were polytransfused and were in advanced phase of disease with severe acquired hemochromatosis. The sites of infection were sinonasal, rhinocerebral-pulmonary, pulmonary and pulmonary-central nervous system. Mucormycosis was the primary cause of death in three of four patients. Two infections were detected within the first 100 days after BMT. Only one of the four patients had partial resolution of sinonasal mucormycosis following aggressive antifungal therapy combined with hyperbaric oxygen treatment.

Pulmonary mucormycosis

Mucormycosis is an opportunistic, angioinvasive fungal infection characteristically affecting individuals with diabetes mellitus, chronic renal failure, and hematologic malignancies. In most cases it is a rapidly progressive infection with an 80% overall mortality. Radiographic manifestations are usually nonspecific focal consolidation or masses. The air crescent sign is a rare manifestation of angioinvasive fungi and indicates either aspergillosis or mucormycosis.