Seasonal variations in rhino-cerebral Mucor infection

OBJECTIVES

Rhino-orbito-cerebral mucormycosis (ROCM) is an uncommon, potentially lethal infection that occurs mostly in immunocompromised hosts. The seasonal occurrence of ROCM was studied in two of Israel's largest medical centers.

METHODS

A total of 36 patients were seen during a 25-year period in this retrospective bi-institutional cohort study. Meteorologic data were obtained and analyzed for a possible linkage of infection with precipitation and temperature.

RESULTS

Twenty-one of the 36 patients (58%) presented between the months of August and October, and 27 patients (75%) presented between the months of August and December. A peak incidence of ROCM was noted in the month of September (13/36 patients; 36%). No association was noted between meteorologic conditions and the incidence of ROCM infection.

CONCLUSIONS

A consistent seasonal peak was observed in ROCM. Heightened awareness is important for early recognition and treatment of this disease.

Early identification of rhinocerebral mucormycosis

OBJECTIVES

Mucormycosis is an acute and often fatal infection caused by a fungus of the Mucorales order of the Zygomycetes class. In the majority of cases, it is associated with an underlying disorder, such as diabetes mellitus with ketoacidosis, or with immunocompromising factors, but it may appear in healthy people, although rarely. Early diagnosis and treatment are critical to prevent an otherwise fatal outcome. This article presents and discusses the early (alarming) signs and symptoms and the predisposing factors that should be considered to avoid delays in diagnosis.

METHODS

We review seven cases of rhinocerebral mucormycosis admitted to our hospitals from 1998 to 2003.

RESULTS

All patients had an underlying immunocompromising factor and/or diabetes mellitus. Five patients had palatal necrotic ulcers and/or black eschars. Three patients had unilateral blindness, and two patients required orbital exenteration. Four patients died because of a delayed diagnosis.

CONCLUSIONS

Early diagnosis is critical in the prevention of intracranial extension of the infection, which is the cause of death in 80% of cases. Therefore, a high index of clinical suspicion is essential in immunocompromised or diabetic patients with acute sinus infection. Identification of a fungal organism on histopathology is the most specific element for diagnosis. A team approach to management is recommended for early surgical debridement, correction of diabetic ketoacidosis, and systemic antifungal agents. Timely medical-surgical treatment proves extremely important for prognosis.

[Rhinocerebral mucormycosis]

INTRODUCTION

Mucormycosis is a rare and acute fungal infection which is frequently lethal. The rhinocerebral form is usually seen in diabetics, but other localizations may occur in severely immunocompromised subjects.

OBSERVATION

We report the case of a sphenoidal sinusitis associated with a probable cavernous sinus thrombosis and carotid artery thrombosis with middle cerebral artery territory infarction. Diagnosis was made on histological examination following sphenoidotomy. Early medical and surgical treatment led to a good outcome.

CONCLUSION

The diagnosis of rhinocerebral mucormycosis should be considered in the clinical setting of necrotic sinusitis and acute neurologic deficit in diabetic patients. Early diagnosis and treatment are crucial factors leading to a good outcome.

[Mucormycosis and diabetes: three cases reported]

Mucormycosis is a rare and often fatal fungal infection. It mainly occurs when predisposing factors such as diabetic ketoacidosis are present. We report three cases of rhino-orbito-cerebral, rhino-orbital and pulmonary mucormycosis in patients with diabetic ketoacidosis. The diagnosis was reached after identification of hypae of the order mucorales using pathology and mycology examinations. A fatal issue occured in two cases and one case survived after adequate therapy.

An immunohistochemical study of canine nasal aspergillosis

In this study, histochemistry and immunohistochemistry were used to characterize the phenotype and distribution of leucocytes in the distal nasal mucosa of 15 dogs with nasal aspergillosis. The most consistent histopathological finding was a severe, predominantly lymphoplasmacytic, inflammatory infiltration of the lamina propria. Fungal hyphae were not observed to invade the mucosa but were found at the mucosal surface and within material collected from the nasal cavity. The main immunohistochemical findings were (1) a predominance of IgG(+) plasma cells over IgA(+) and IgM(+) plasma cells, (2) significant numbers of macrophages and dendritic cells expressing MHC class II molecules, (3) macrophages and neutrophils expressing L1 antigen and (4) a mixture of CD4(+) and CD8(+) T cells. These findings are consistent with a dominant Th1-regulated cell-mediated immune response. The nature of the inflammatory infiltrate and the lack of invasiveness of the mucosa by the fungus, together with the clinical course of the disease and the apparent immunocompetence of the affected dogs, suggest that canine nasal aspergillosis resembles the chronic erosive non-invasive fungal sinusitis described in human patients.

[Nasal cutaneous cryptococcosis localization]

Cryptococcosis is a polymorphous disease occurring especially in the course of the Acquired Immuno Deficiency Syndrome (AIDS). It puts so diagnostic that therapeutical problems in African countries. The objective of this observation is to report a case of nasal localization with a cutaneous cryptococcosis. It has been confirmed by the histopathologic study of the cutaneous biopsy. The patient was 42 year-old female, HIV positive, bachelor and hospitalised for epistaxis with cutaneous tumefaction and lesions of the nose. The rate of CD4 was 98/mm3. The treatment was based on amphotericine B. Patient died from neuro meningitis extension of the disease.

Fatal strokes in patients with rhino-orbito-cerebral mucormycosis and associated vasculopathy

Within a 10-y period, fatal strokes occurred during parenteral administration of amphotericin B and surgical debridement of paranasal sinuses in 6 pathologically verified cases of rhino-orbito-cerebral mucormycosis (ROCM). All patients had unnoticed type-2 diabetes mellitus without ketoacidosis. They presented with unilateral orbital cellulitis and cavernous sinus syndrome. Fatal malignant cerebral infarctions occurred in the carotid system in 5 patients, and in the basilar artery or its major branches in 2 patients. Accelerated thrombotic occlusion of the cavernous portion of the carotid artery or the basilar artery was likely to be due to mucormycosis associated-vasculopathy and diabetic vasculopathy. One patient died of massive subarachnoid hemorrhage following rupture of the mycotic aneurysm. Despite parenteral administration of amphotericin B, fatal outcome of ROCM in patients with unnoticed diabetes mellitus occurs due to mucormycosis-associated malignant strokes. To improve outcome, a combination of early radical debridement, ocular exenteration, parenteral and local administration of amphotericin B, and decompression craniotomy should be considered.

Improved outcome of zygomycosis in patients with hematological diseases?

Zygomycosis is an opportunistic fungal infection that is increasingly reported in hematological patients. We describe 2 cases of successfully treated rhino-cerebral zygomycosis and give an overview of 120 patients from the literature with underlying hematological or oncological disorders. These data document the improved survival in sinus (15/17 patients surviving) and cutaneous (6/9 patients surviving) disease. Hematological patients with pulmonary (9/30 patients surviving) or disseminated (4/38 patients surviving) zygomycosis still have a poor prognosis. The clinical course of sinus-orbital involvement (4/11 patients surviving) follows sinus-cerebral (2/3 patients surviving) or cerebral (3/6 patients surviving) disease. Besides deoxycholate amphotericin B (AmB) (24/62 patients surviving), patients seem to benefit from liposomal amphotericin B (L-AmB) (10/16 patients surviving) or sequential AmB/L-AmB treatment (6/8 patients surviving). Alternative treatment options lead only in a few patients to success.

[The clinical and pathological features of rhinocerebral mucormycosis]

OBJECTIVE

To investigate the clinical and pathological features of rhinocerebral mucormycosis.

METHODS

The clinical data of three cases of mucormycosis were collected and analyzed. Pathological examination was conducted by autopsy or biopsy.

RESULTS

All the three cases of mucormycosis had diabetic ketoacidosis. The early symptoms were fever, periocular and temporal headache. Gradually, orbital apex syndrome, periocular skin cellulitis and necrosis developed. Examination of nose revealed black necrotic turbinates. Meningeal signs and hemiplegia may also occur. Frontal hemorrhagic infarction was seen in pathology. A large amount of mucor fungi were found in the mucosa of nasal sinuses necrotic brain tissue under microscope.

CONCLUSIONS

Rhinocerebral mucormycosis is a rare complication which was mainly seen in patients with diabetic ketoacidosis. The lesion invaded nose, eyes and brain with a high mortality.

Naso-orbicular tissue necrosis by Streptococcus parasanguis in a patient with Fanconi anemia: clinical and laboratory aspects

Fanconi anemia (FA) is a rare autosomal recessive disorder, characterized by pancytopenia and progressive hypoplasia of the bone marrow. A 23-year-old woman with FA showed severe pancytopenia and developed an abscess on the infraorbicular region on the right side of the face that progressed to phlegmon and caused tissue necrosis of the nostrils, nasal septum, nasal fossa, and posterior orbital region. Laboratory examination showed Streptococcus parasanguis as the etiologic agent of the phlegmon. Supportive treatment was recommended due to donor incompatibility for bone marrow transplant. The intraoral examination showed spontaneous gingival bleeding, edema of the interdental papillae, hematomas on the superior and inferior lips, bacterial and fungal infections, and adequate oral hygiene. The patient was treated with the administration of an antibiotic (imipenem), an antifungal (amphotericin B), and mouth washing with antiseptic solutions. Periodontal prophylaxis and orientation to and control of oral hygiene and diet were also used during the remission period. For functional and esthetic rehabilitation of the alar regions and nasal dorsum, an acrylic resin nasal prosthesis was made, supported by a spectacle frame.

Mucormycosis causing extensive destruction of maxilla

Mucormycosis is a rare, often fatal opportunistic infection caused by a saprophytic fungus belonging to a class of Phycomycetes. It is characterized by its unrelenting progression towards vital organs with marked propensity towards arterial wall by direct extension producing vascular thrombosis leading to ischaemic necrosis. In normal circumstances the saprophytes are not pathogenic but represent opportunist-requiring impairments in patient's resistance to disease. If not treated the disease may prove fatal. We report a case of Mucormycosis with extensive necrosis of the maxilla in a 57-year-old patient suffering from uncontrolled diabetes with ketoacidosis.

Septal perforation secondary to Mycobacterium kansasii infection

We report the first recorded case of a septal perforation caused by Mycobacterium kansasii. This atypical mycobacterium is finding increasing prevalence with the increasing incidence and longevity of human immunodeficiency (HIV) infections. Cases of chest infection, sinusitis, septic arthritis, osteomyelitis, pericarditis, brain abscess, cutaneous and oral lesions have all now been reported. This discovery represents a rare but important differential in the aetiology of septal perforation.

Oral manifestations of paracoccidioidomycosis. Report of 21 cases from Argentina

The present study describes 21 Argentinian patients living in the province of Corrientes, who had developed oral manifestations due to Paracoccidioides brasiliensis infection. Of these, 20 patients were men and one a woman. Patients were of an average age of 39 years (range 25 to 72 years). Approximately, 76.2% of the patients were farmers. Gingival lesions were observed in 76%. Also, the tongue (71%) and the lips (62%) were frequently affected. Cytological smears and histopathology showed the characteristic fungal cells with the characteristic granulomatous inflammatory reaction consisting of lymphocytes, epithelioid cells and giant cells of the Langhans type. All patients except one had detectable pulmonary involvement. Therapy consists of long-term administration of itraconazole. Oral manifestations of paracoccidioidomycosis are characteristic in their clinical presentation. Early diagnosis and adequate therapy may prevent extensive tissue destructions. Long-term follow-up is mandatory.

Mucormycosis--early diagnosis and treatment

OBJECTIVE

The aim of this retrospective study was to analyse the data of patients with rhino-orbital-cerebral mucormycosis for predisposing factors, diagnosis, treatment and survival rate. The role of frozen section in early diagnosis and use of nasal endoscopy in diagnosis, treatment and follow-up of patients has also been examined.

DESIGN

Retrospective case series.

SETTING

University Teaching Hospital.

METHODS

The case notes of 9 patients with diagnosis of mucormycosis who presented from 1973 to 2001 were examined. The data for predisposing factors, signs/symptoms, histological diagnosis, radiological intervention, medical and surgical treatment and final outcome was analysed.

RESULTS

There were 9 patients with mucormycoses. Early diagnosis was made by endoscopic examination and frozen section in 5 patients, which was later confirmed by histology. Treatment included parental and/or local amphotericin, hyperbaric oxygen and debridement either by endoscopic or external approach, with or without orbital exenteration. This resulted in an overall survival of 5 patients.

CONCLUSION

Frozen section diagnosis allows for early therapy since successful treatment depends on systemic amphotericin, surgical debridement and treatment of underlying predisposing factors. Nasal endoscopy is useful in diagnosis, endoscopic debridement and follow up of patients.

Colonization of the cleft nasal floor by anaerobic oral flora in patients with oronasal fistulae

OBJECTIVES

Aerobic oral bacteria only rarely colonize the cleft nasal floor in patients with patent oronasal fistula. There are no studies that have investigated whether anaerobic oral flora colonize this site and whether attempting to culture them is useful for assessing the patency of oronasal fistulae in the clinic.

DESIGN

A prospective study of 13 patients with cleft with patent unilateral oronasal fistulae. Microbiological culture swabs were taken from the oral cavity and both nasal floors, with the unaffected side being used as a control. Following aerobic and anaerobic culture, bacterial isolates were identified and compared.

MAIN OUTCOME MEASURE

A significant growth of anaerobic oral bacteria from the cleft nasal floor when compared with the unaffected side.

RESULTS

Aerobic oral flora was cultured from the oral cavity in all 13 patients. A light growth of aerobic oral flora was found in the cleft nasal floor in two patients, and anaerobic oral flora was cultured from the cleft nasal floor in the same two patients. No statistical correlation was found between growth of anaerobic flora and the cleft nasal floor (p =.48).

CONCLUSIONS

Like aerobic oral flora, anaerobic oral bacteria would appear to only rarely colonize the cleft nasal floor in patients with oronasal fistulae. This additional investigation does not appear to be helpful in the assessment of oronasal fistulae in the clinic.

Mycotic bovine nasal granuloma

A case of mycotic bovine nasal granuloma in a 10 year-old Jersey cow, produced by Drechslera halodes is presented. Histopathological sections showed abundant hyaline and pigmented extra and intracellular fungal structures together with a polymorphic cellular granuloma formed by neutrophils, lymphocytes, plasmocytes, histiocytes and giant cells of the Langhans type. It is the first case of mycotic bovine nasal granuloma recognized in Uruguay although this disease seems to be frequent according to the opinion of veterinarian specialists. Another similar clinical case also in a Jersey cow from the same dairy house with an intense cellular infiltrate rich in eosinophils without granulomatous image, together with extracellular hyaline and fuliginous fungal forms, is also referred for comparative purposes. Geotrichum sp. was isolated. The need of an early diagnosis and treatment of the disease is stressed.

Nostril infection due to Mycobacterium marinum in an immunocompetent host

Mycobacterium marinum infection developed in the nostril of an immunocompetent host whose only risk factors were infrequent swimming and cleaning of a small fish bowl on a single occasion. The lesion relapsed after 2 surgical excisions but resolved slowly with a 9-month course of trimethoprim/sulfa therapy.

Orofacial conidiobolomycosis due to Conidiobolus incongruus

We report here a patient of orofacial conidiobolomycosis presenting with classical centrofacial distribution described typically for Conidiobolus coronatus infection. The culture, however, showed C. incongruus. The mode of infection and its possible correlation with patient's occupation is also discussed.

[Chronic invasive rhinocerebral mucormycosis]

Rhinocerebral mucormycosis is a fulminant fungal disease that typically presents acutely in patients with diabetic ketoacidosis or immunosuppression. The case of a 55 year-old male patient is presented; the patient experienced chronic infection that involved nose, paranasal sinuses, hard palate, orbit, pterygopalatine fossa, infratemporal fossa with cavernous sinus thrombosis and compression of the internal carotid artery which develops in insidious manner after metabolic imbalance with predominantly ocular symptoms. The patient was managed with Amphotericin B and radical surgical debridement of affected tissue, the patient presenting cure without complications or added disabilities.

[Facial mucormycosis: observations from three cases]

The mucormycosis is a rare opportunistic invasive infection caused by fungi of the order Mucorales and characterized by vascular invasion and tissue necrosis. It affects generally the subjects with altered natural resistances, particularly the diabetics patients. The cerebro-rhino-orbital region is the most common site. The clinical signs depend on the intra-tissular and intra-vascular evolution of the fungi. The diagnosis of this disease is asserted by the mycological and anatomo-pathological exams. The treatment is based on the antifungic and the surgical excision of necrotic tissues. We report three observations: one man (42 years) and two women (59 and 60 years). Diabetes was found in two cases. The diagnosis was in every case anatomo-pathologic. Our objective was to study the epidemiological and clinico-pathologic aspects of this serious affection and to discuss its prognosis.

An unusual case of primary nasal tuberculosis with epistaxis and epilepsy

Primary nasal tuberculosis is rare. We report a case that was all the more extraordinary because of the age and sex of the patient (an 11-year-old boy), the unusual associated symptoms (epistaxis and grand and seizures), and the presence of intracranial extension. Clinical and radiologic findings on our initial evaluation suggested that the patient had a large sinonasal malignancy. The patient manifested no evidence of pulmonary tuberculosis. The diagnosis of primary nasal tuberculosis was established only after we obtained the results of histopathology of the excised mass and a subsequent tuberculin skin test; the diagnosis was confirmed by the patient's rapid response to antituberculosis drug therapy. We also review the relevant literature on this rare condition.