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.

Spontaneous regression of pulmonary mucormycosis

A case of pulmonary mucormycosis with spontaneous resolution is presented. The patient had no known underlying predisposing disease.

Pulmonary zygomycosis: CT appearance

OBJECTIVE

We describe the CT appearance of pulmonary zygomycosis (mucormycosis), an opportunistic infection typically occurring in immunocompromised patients.

MATERIALS AND METHODS

Eight patients with pulmonary zygomycosis imaged with CT were reviewed, seven at initial diagnosis and one with a subsequent complication. The appearance, number, and location of pulmonary lesions and the presence of pleural effusions and extrapulmonary involvement were assessed. Rim enhancement, air bronchograms, the halo sign, air crescent sign, cavitation, and central low attenuation suggesting necrosis were recorded.

RESULTS

There were 14 nodules and 5 areas of mass-like or wedge-shaped consolidation. Pleural effusion was present in five patients, halo sign in three, central low attenuation in two, and cavitation in one. In the affected lobe 13 of 14 nodules and all consolidations were posterior. Of 19 lesions 16 (84%) were confined to the upper lobes, with 3 in the superior segment of a lower lobe. Endobronchial disease with lobar collapse was the only manifestation in one patient. Major complications were direct spinal invasion in one patient and multiple pulmonary artery pseudoaneurysms in another patient.

CONCLUSION

In the appropriate clinical circumstance, nodules or mass-like or wedge-shaped consolidation, especially posteriorly in the upper lobes of the lung, should suggest zygomycosis. Endobronchial zygomycosis is less common.

Successful treatment of invasive thoracopulmonary mucormycosis in a patient with acute lymphoblastic leukemia

BACKGROUND

Pulmonary mucormycosis associated with hematologic malignancy is an uncommon, but important opportunistic fungal pneumonia that is usually a fatal infection. Only a few survivors of pulmonary mucormycosis have been reported.

METHODS

A case report of invasive thoracopulmonary mucormycosis during remission-induction therapy for acute lymphoblastic leukemia and a review of the literature are presented.

RESULTS

The fungal lesions extended to both lungs, the left ribs, and intercostal muscles. Percutaneous needle biopsy and immunostaining of the fungal hyphae established the diagnosis of thoracopulmonary mucormycosis. The patient was treated with granulocyte-colony stimulating factor (G-CSF) and intravenous amphotericin B for 9 weeks and the lesions in the right lung disappeared. Left pneumonectomy and partial resection of the chest wall were later performed. The left lung was grossly necrotic and contained a large cavity and bronchopulmonary fistula. Thereafter, antileukemic therapy was resumed and completed without recurrence of mucormycosis or leukemia.

CONCLUSIONS

In the management of mucormycosis, the addition of G-CSF to the conventional treatment may substantially improve outcome.

Isolated pulmonary mucormycosis in an apparently normal host: a case report

Mucormycosis is a rare fungal disease commonly affecting individuals with diabetes mellitus, hematological malignancy, and immune deficiency. Isolated pulmonary mucormycosis is extremely rare. This article reports a case of isolated pulmonary mucormycosis that presented as a solitary cavity infiltrate in a patient with no underlying risk factors.

Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals

We report the computed tomographic appearance of invasive fungal disease of the paranasal sinuses in 13 patients. Coronal and axial computed tomographic images were obtained in each patient and data were analysed. Eight patients had Aspergillus flavus infection, four had Mucormycosis, and one had mixed Candida and Mucor. Our experience was different from that of other workers in many respects. All of our patients were immunocompetent. On radiological imaging by computed tomography, ethmoid sinuses were involved in 85% of our patients. In previously reported series maxillary sinuses were most frequently affected. Calcification in the inflammatory mass was not encountered in any of our patients, whereas this feature was present in many reported cases. Features in our patients that were similar to other studies were contrast enhancement, extension of the disease into the orbit and cranial cavity and a high mortality. The clinical course and radiological features of invasive mycosis simulate malignancy. Certain features that may help to differentiate invasive fungal infection from malignancy are discussed. We conclude that invasive fungal infection can affect immunocompetent individuals and should be considered in the differential diagnosis in appropriate clinical settings.

Hyperbaric oxygen therapy for rhinocerebral fungal infection

Rhinocerebral mucormycosis is an acutely fatal fungal infection that usually arises in the ethmoid sinuses, spreads into the orbits and then into the cranial cavity. It is typically seen in diabetic or immunocompromised patients. Therapy includes aggressive surgical debridement, administration of high-dose amphotericin-B and control of underlying predisposing conditions. Adjunctive hyperbaric oxygen (HBO) is another treatment modality that appears to be promising; oxygen in sufficient concentrations is fungicidal and decreases acidosis thereby increasing tissue survival. It is important for the neuroscience nurse to have an understanding of this deadly infection and the role in preparing the patient for HBO therapy to better plan care.

[Mucormycosis: an uncommon case of cellulitis of the face and multiple facial lymphadenopathies]

An unusual case of mucormycosis is presented: a cutaneous form characterized by an extension to the soft tissues of the face with a noticeable involvement of facial lymph nodes. The successive CT studies enable the description of the lesions and their follow-up.

Renal mucormycosis: computerized tomographic findings and their diagnostic significance

Isolated renal involvement by mucormycosis has been reported rarely in immunocompromised individuals. We describe four patients with mucormycosis confined to the kidneys, three of whom did not exhibit any predisposing factors. Only one patient had acute viral hepatitis with fulminant hepatic failure as the preceding disease. Two patients presented with oliguric renal failure of undetermined etiology and investigations revealed bilateral extensive involvement of the kidneys. Computerized tomography showed diffuse enlargement of the kidneys and multiple low-density areas. Treatment included systemic amphotericin B therapy in all four patients and nephrectomy in three patients. Two patients recovered completely. Our experience emphasizes the need for a high index of suspicion and recognition of computed tomographic scan appearances for making a prompt diagnosis. Early surgical intervention and systemic antifungal therapy are necessary for survival in this life-threatening condition.

Recovery from rhinocerebral mucormycosis in a ketoacidotic diabetic patient: a case report

An 18-year-old woman with insulin-dependent diabetes mellitus developed an infection of the paranasal sinuses with Rhizopus oryzae resulting in facial swelling, hemiplegia and blindness of the right eye. The therapy of this rhinocerebral mucormycosis consisted of extensive surgical debridement, administration of high-dose amphotericin B, hyperbaric oxygen and control of the underlying predisposing diabetes mellitus. The patient eventually recovered with however, the loss of one eye.

[A patient with chronic mucormycosis]

Rhinocerebral mucormycosis was diagnosed in a 75-year-old woman with a history of type II diabetes mellitus. This rare opportunistic infection is caused by fungi belonging to the order of Mucorales. The patient had a severe osteomyelitis of the base of the skull, resulting in complaints of headache and diplopia. She was treated with intravenous colloidal amphotericin B, surgical excision, and later with liposomal amphotericin B. She died of respiratory failure. Mucormycosis is usually a rapidly fulminant infection. This patient showed a remarkably chronic course.

Pulmonary zygomycosis: a radiographic and clinical spectrum

Eight documented cases of pulmonary zygomycosis were analyzed retrospectively with regard to radiographic and clinical features. Predisposing factors were diabetes mellitus in six cases, lymphoblastic lymphoma in one case, and surgery to correct a tracheoesophageal fistula in one case. Two of the patients with diabetes had also undergone renal transplantation for diabetic nephropathy and were immunosuppressed. The more usual radiographic findings of pulmonary zygomycosis represent a spectrum that comprises a normal chest radiograph, a lung abscess, subacute or chronic pneumonia that often evolves into a lung abscess, and rapidly progressive fatal pneumonia. Awareness of the various presentations of pulmonary zygomycosis is important because early diagnosis and appropriate therapy clearly have been shown to improve the survival rate of these patients. Zygomycosis should be included in the differential diagnosis when patients with diabetes mellitus, patients with leukemia or lymphoma, or immunocompromised patients present with or develop perplexing pulmonary abnormalities.

Pseudoaneurysm of pulmonary artery in mucormycosis. Radiographic characteristics and management

Pulmonary mucormycosis is a rare and almost invariably fatal complication that can occur in the context of severe deficits in host defenses. Antemortem diagnosis is difficult and requires a high index of suspicion together with invasive diagnostic techniques. Mucor species exhibit a pronounced affinity to invade vessels; mucormycosis involving the pulmonary vasculature has rarely been documented antemortem, and survival in this context has been rare. In this report, we describe a patient with chronic renal failure and systemic lupus erythematosus who developed extensive invasion of the left main pulmonary artery by mucormycosis. Chest computed tomographic (CT) scans and pulmonary arteriogram demonstrated a massive pseudoaneurysm of the left pulmonary artery; these radiographic findings have not previously been described in mucormycosis. Aggressive combination therapy, employing preoperative amphotericin B (AmB) followed by surgical resection (pneumonectomy) and a full course of AmB, was curative. This favorable outcome supports the role of surgery as adjunctive therapy, and it underscores the need for early diagnosis and aggressive treatment.

Granulomatous pulmonary zygomycosis in a patient without underlying illness. Computed tomographic appearances and treatment by pneumonectomy

Pulmonary zygomycosis rarely occurs in the absence of underlying disease. We report a patient with granulomatous pulmonary zygomycosis without underlying disease who presented with a pulmonary mass. We present the computed tomographic findings that we believe have not been described previously. We also report the successful treatment by pneumonectomy.

Orbital lesions with granulomatous inflammation

Orbital lesions characterized by granulomatous inflammation are a heterogeneous group of diseases of various causes with a common histopathological substrate involving aggregates of epithelioid cells. Forty-one patients (27 females and 14 males) with biopsy-proven granulomatous inflammation were seen at an orbital clinic between 1978 and 1989. The mean age at presentation was 40.2 (extremes 6 and 77) years. Two main clinical presentations were noted: painless, subacute or chronic mass effect, and tender, subacute inflammatory process. Six patients had secondary features that were infiltrative in character. The lesions were primarily located in the anterior superior orbit. In nearly half the patients the granulomatous reaction was confined to the orbit (predominantly ruptured dermoid and localized orbital sarcoid), and the remainder had either regional involvement (Wegener's granulomatosis or fibro-osseous process) or systemic involvement (sarcoidosis).

Phycomycosis infection in acute leukaemia

Fungal infections are increasingly being reported in patients with acute leukaemia on intensive induction chemotherapy protocols. The common fungi seen are candida, aspergillus and mucormycosis. We have seen 3 cases of mucormycosis over the last 4 years. All 3 patients had acute leukaemia-two had acute lymphoblastic and one acute myeloid leukaemia. All patients were in neutropenic phase after induction chemotherapy. Features suggestive of fungal infection were fever and development or progression of pulmonary infiltrates despite antibiotic therapy. Repeated body fluid cultures were negative in two patients. In the first patient, the diagnosis was confirmed after biopsy of a palatal mass; he was treated successfully with amphotericin-B. In two patients the diagnosis was confirmed at autopsy. A high degree of suspicion in febrile, neutropenic cancer patients on chemotherapy and early administration of amphotericin-B may improve the outcome. With dissemination, the prognosis is poor.

Mucor cerebral abscess associated with intravenous drug abuse

We report on a case of a 26-year-old intravenous narcotic abuser with a primary cerebral mucormycotic abscess caused by Rhizopus oryzae. He was treated with a combination of intravenous and intraventricular amphotericin B and surgical drainage with a successful outcome. There was no evidence that his infection was acquired by the rhinocerebral route, it seems likely that he injected himself with a contaminated batch of narcotic or amphetamine. Mucormycosis presenting in this way has been described previously but this is only the second such case to survive. Early diagnosis and treatment is essential for a favourable outcome in this condition.