Chronic rhinocerebral mucormycosis

Rhinocerebral mucormycosis is a well-described fulminant fungal infection that typically presents acutely in patients with diabetic ketoacidosis or immunosuppression. Chronic presentations of rhinocerebral mucormycosis have also been described. In the chronic infection, the disease course is indolent and slowly progressive, often occurring over weeks to months. The authors report 2 cases of chronic rhinocerebral mucormycosis (CRM) treated at their institution and review 16 other cases reported in the English-language literature. In these cases, the median time from symptom onset to diagnosis was 7 months. The most common presenting features of CRM are ophthalmologic and include ptosis, proptosis, visual loss, and ophthalmoplegia. CRM occurs predominantly in patients with diabetes and ketoacidosis. The incidence of internal carotid artery and cavernous sinus thrombosis is higher in CRM patients than in those with the acute disease, although the overall survival rate for CRM patients is 83%. CRM is clinically distinct from chronic Entomophthorales infection.

Entomophthoramycosis: therapeutic success by using amphotericin B and terbinafine

A 12-year-old girl had been presenting a woody infiltration and erythema in the frontal region and on the entire left half of the face, leading to deformity of the nose and buccal fissure, and adenomegaly in a posterior cervical chain, for the last 18 months. Sinusitis was diagnosed and treated with antibiotics, and submitted to ethmoid sinusotomy, with no improvement. Several laboratory tests were made to find the correct diagnosis. An intradermal test for delayed hypersensitivity showed a positive reaction (5 mm) with necrosis for metabolic antigens for Conidiobolus. An oral mucosa biopsy showed a dense lymphohistiocytic infiltrate and focal points of necrosis. Gomori staining for fungi revealed countless wide, nonseptate hyphae. Amphotericin B was prescribed during 35 days, with no improvement. Terbinafine given orally was started in association with amphotericin B. Reduction of the lesions was observed 2 months later. No side effects were seen during 4 months of treatment.

Tuberculosis of the nasal fossa manifested by a polypoid mass

Since the introduction of effective antituberculous chemotherapy, upper respiratory tract tuberculosis is infrequent; nasal involvement is a very rare form of this disease. In this localization, tuberculosis is usually unilateral and typically discloses a definite granular mass or an ulcer. We report a case manifested by an intranasal mass on computerized tomography scans that evolved as chronic rhinitis.

Acute rhinocerebral mucormycosis caused by Rhizopus arrhizus from Sri Lanka

Rhinocerebral mucormycosis is a rare fungus infection reported mainly from the United States of America and Europe. The disease is caused by zygomycete fungi, most often by a Rhizopus species. Diagnosis is often made post-mortem and in many instances culture identification of the fungus responsible has not been performed. A case of culturally proven rhinocerebral mucormycosis is described for the first time in Sri Lanka. The patient was a 56-year-old male who had been treated for diabetes mellitus for 17 years. He had typical symptoms of numbness and loss of sensations over the temporal region, followed by loss of vision and proptosis, all on the right side of his face. The diagnosis of rhinocerebral mucormycosis was confirmed by microscopic examination and culture of material obtained from the retro-orbital space. The patient died before effective antifungal therapy could be instituted.

Coccidioidomycosis: the other great imitator

A "great imitator," like the perhaps more familiar syphilis and tuberculosis, coccidioidomycosis has a wide variety of clinical presentations. A recent dramatic surge in the incidence of this saprobe increases the likelihood that clinicians will encounter an infected patient. Although rare, the disseminated form of the disease is potentially fatal. Vigilance and familiarity with the many faces of this pathogen will permit early detection and treatment. We present two cases of disseminated coccidioidomycosis and briefly review this increasingly common fungal infection.

Mixed intranasal infection caused by Fusarium solani and a zygomycete in a leukaemic patient

We report a case of mixed intranasal infection caused by Fusarium solani and a zygomycete, with probable sinus and brain involvement. The patient had chronic myelogenous leukaemia and was treated with chemotherapy. Diagnosis of the infection was established by direct examination of the intranasal eschar and histopathological study of an excisional biopsy. Only F. solani was isolated from both specimens. Difficulties in diagnosis and treatment of these infections are discussed.

Infectious emergencies in patients with diabetes mellitus

Although it remains controversial as to whether diabetics have an overall increased incidence of infection as compared to nondiabetics, several potentially life-threatening infections do appear to be uniquely associated with diabetes. These infections generally occur in older diabetics with less than optimal glucose control. For each entity, selected symptoms and signs may suggest the diagnosis but confirmation of via tissue biopsy with culture and histopathology or radiography is usually necessary. Management typically require both antimicrobial treatment and surgery.

Survival factors in rhino-orbital-cerebral mucormycosis

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

Evaluation of methods for the detection of nasal carriage of Staphylococcus aureus

In the present study we investigate the optimal methodology for determination of the nasal carriage rate of Staphylococcus aureus. Tests were performed on 91 healthy laboratory staff. The reproducibility of different sampling, transportation, storage and culture methods was examined. We compared sterile dry cotton wool swabs with sterile dry cotton wool swabs impregnated with charcoal and 5% blood agar plates with mannitol salt agar plates after different incubation periods. Finally, we investigated the detection rate for S. aureus following direct plating compared to storage in Stuart's transport medium for 7 days. There were no differences in isolation rates from the right or left nostril using either cotton or charcoal swabs. Charcoal swabs gave an increased isolation rate as compared to cotton swabs, and incubation in broth enrichment medium containing 6.5% NaCl also increased the isolation rate. Storage in Stuart's transport medium for 7 days gave an increase in isolation rate as compared to direct plating on blood agar. With mannitol salt agar plates the increase in isolation rate when incubation was performed for from 2 to 4, 2 to 7, and 4 to 7 days was 5.9%, 16.7%, and 11.5%, respectively. For the detection of S. aureus nasal carriers we find the use of charcoal swabs and Stuart's transport medium combined with cultivation on mannitol salt agar for 7 days to be the optimal method.

Bacillary angiomatosis: a new entity in acquired immunodeficiency syndrome

Since the recognition of the acquired immunodeficiency syndrome (AIDS) in 1981, previously rare infections and neoplasms have become increasingly common. Bacillary angiomatosis, undescribed in the medical literature prior to 1983, is now second in frequency only to Kaposi's sarcoma with respect to the cutaneous manifestations associated with human immunodeficiency virus (HIV) infection. Caused by Rochalimaea henselae, bacillary angiomatosis is easily treated, when diagnosed early, with erythromycin. We present two cases of bacillary angiomatosis that presented to Toronto General Hospital and review this new and clinically interesting entity. The incidence of bacillary angiomatosis will undoubtedly increase as the HIV epidemic accelerates. Since bacillary angiomatosis commonly affects the head and neck region, it is important for the otolaryngologist to become increasingly proficient in its diagnosis and treatment. The current AIDS crisis demands that the otolaryngologist become aware not only of bacillary angiomatosis, but also of the other cutaneous head and neck manifestations of HIV infection.

[The role of microorganisms in the genus Staphylococcus in the origin and development of nasal furuncles]

It is shown that Staphylococcus aureus carriage in the nasal mucosa and nasal furuncle risk are related. The severity of nasal furunculosis depends much on the spectrum of biological and virulent characteristics of the microorganism. It is recommended to determine pathogenetic potential of the causing agent by comprehensive examination of its virulence.

Rhinocerebral mucormycosis: changing patterns of disease

Eleven cases of rhinocerebral mucormycosis (RM) encountered over a 13-year period were reviewed. Predisposing factors included leukemia (36%), diabetes mellitus (27%), aplastic anemia (9%), myelodysplastic syndrome (9%), and treatment with immunosuppressive medications necessary to maintain solid organ or bone marrow graft viability (64%). Two patients had no predisposing factors. Clinical findings included headache (73%), fever (55%), black nasal eschar (45%), orbitofacial cellulitis (36%), cranial nerve palsy (36%), altered sensorium (36%), and hemiparesis (27%). Seven patients presented with destruction of the paranasal sinuses and local invasion; three with direct extension to the frontal or temporal lobes. Four patients displayed hematogenous dissemination to the cerebrum, brain stem, and cerebellum from a primary pulmonary focus. The seven patients with sinus involvement were treated with aggressive surgical debridement. Two patients with focal intracerebral lesions underwent either open craniotomy or stereotactic biopsy. Amphotericin B was administered intravenously to all patients. Local irrigation via a percutaneous catheter was performed in the seven patients with sinus disease and in one case of intracranial abscess. All seven patients with intracranial infection died, in contrast to four patients that survived with infection localized to the sinuses and orbits. All survivors had been treated with a combination of surgery and amphotericin B therapy. This review demonstrates that RM is increasingly affecting patients with sources of immunosuppression other than diabetes mellitus. Early aggressive therapy to prevent cerebral involvement by this severe infection provides the best chance for a good outcome.

Ultrastructure of human nasal epithelium during an episode of coronavirus infection

The nasal epithelium from a young girl was examined by electron microscopy and found to be infected by coronavirus. Virions are seen within and outside the ciliated cells, but not outside or within the goblet cells or other cells of the nasal mucosa. Some virions are located near the microvilli, others in pockets in the apical cell membrane. The cytoplasm contains many small vesicles with a single virion, large apical vesicles containing hundreds of virions, and lysosome-like cytosomes with a moderate number of virions. Some virus-like particles devoid of an electron-dense interior are seen both in the cytosomes and extracellularly. Virus budding was observed in the Golgi apparatus but nowhere else in the cell. The ciliated cells seem not to be destroyed by the viruses, although in many cases the cilia are withdrawn into the cell body. The loss of cilia is likely to cause rhinorrhoea.

Clinical signs of orbital ischemia in rhino-orbitocerebral mucormycosis

Mucormycosis is the most acutely fatal fungus infection of man (Ferry and Abedi). The most common clinical type of infection is rhino-orbitocerebral mucormycosis. Prompt recognition of the clinical picture is essential if the appropriate urgent management is to be instituted without delay. The presence of black eschar in the region of the nasal passages, palate, midface, and orbit is the best-recognized clinical sign alerting the clinician to the diagnosis. Black eschar is, however, a feature in only a minority of these patients at the time of presentation. This paper discusses other clinical signs, particularly orbital ischemia, which should suggest the diagnosis. The clinical presentation of orbital ischemia in mucormycosis includes proptosis, total external and internal ophthalmoplegia, and early blindness. A lax, nontender periorbital puffiness, which does not feel warm to the examiner's touch, is typical. Proptosis and chemosis, if present, are mild. These signs are compared with those of pyogenic orbital cellulitis, with which the condition might most easily be confused.

Identification of Mycobacterium tuberculosis DNA in five different types of cutaneous lesions by the polymerase chain reaction

BACKGROUND AND DESIGN

A spectrum of skin lesions are believed to be secondary to the presence of Mycobacterium tuberculosis. Demonstration of M tuberculosis directly or in culture in some of these eruptions can be difficult. We used the polymerase chain reaction and a primer/probe set specifically for M tuberculosis complex DNA to evaluate five types of skin lesions clinically considered to represent infection by, or reaction to, M tuberculosis.

OBSERVATIONS

Mycobacterium tuberculosis DNA was demonstrated in paraffin-embedded sections of these five cases, representing a variety of clinical and histologic patterns. In two cases, M tuberculosis could not be demonstrated by routine cultural methods.

CONCLUSION

DNA diagnostic methods such as the polymerase chain reaction can be used to rapidly identify cutaneous lesions produced by M tuberculosis.

Nasal septal abscess--retrospective analysis of 14 cases from University Hospital, Kuala Lumpur

Fourteen patients who presented to the University Hospital of Kuala Lumpur between June 1981 and June 1991 were reviewed retrospectively. Nasal septal abscesses are uncommon and therefore there are limited reports in the medical literature. Early diagnosis and immediate therapy is mandatory to avoid cosmetic nasal deformity or intracranial infection. Two out of the fourteen patients developed saddle nose deformity and septal perforation because of delay in treatment, the cases were misdiagnosed by non-otolaryngologist as turbinates swelling. The leading cause of nasal septal abscess was non-surgical trauma which accounted for about 85.7%. The commonest pathogenic organism isolated from the pus of nasal septal abscess was Staphylococcus aureus.

Cerebral aspergillosis in immunologically competent patients

Aspergillosis of the central nervous system is a rare disease, especially if the patient's immune system is not compromised. The authors report three cases of cerebral aspergillosis in the immunocompetent state: a rhinocerebral form in a diabetic patient, a direct extension from chronic Aspergillus otitis media, and a postoperative Aspergillus brain abscess after brain tumor surgery. In spite of the poor prognosis of cerebral aspergillosis, two of the patients survived. The pathogenesis, predisposing factors, radiologic findings including magnetic resonance image, and the outcome are presented. The pertinent literature of cerebral aspergillosis is also reviewed.

Rhinocerebral zygomycosis in acute lymphoblastic leukaemia

We describe a patient with acute lymphoblastic leukaemia who developed rhinocerebral zygomycosis during the aplastic phase induced by antineoplastic chemotherapy. The patient was treated with fluconazole intravenously (400 mg daily) for 30 days and underwent surgical debridement. As a result of this treatment a complete remission of the zygomycosis-associated symptoms was observed. The possibility of treating zygomycosis with fluconazole is discussed.