Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes

Mucormycosis in India: unique features

Mucormycosis remains a devastating invasive fungal infection, with high mortality rates even after active management. The disease is being reported at an alarming frequency over the past decades from India. Indian mucormycosis has certain unique features. Rhino-orbito-cerebral presentation associated with uncontrolled diabetes is the predominant characteristic. Isolated renal mucormycosis has emerged as a new clinical entity. Apophysomyces elegans and Rhizopus homothallicus are emerging species in this region and uncommon agents such as Mucor irregularis and Thamnostylum lucknowense are also being reported. This review focuses on these distinct features of mucormycosis observed in India.

Rhino-Orbital-Cerebral Mycosis and Cavernous Thrombosis

Rhino-orbital-cerebral mycosis (ROCM) is a life-threatening fungal disease associated mostly with Mucoralean fungi. The infection presents as headache, vision loss, proptosis, ptosis, painful ophthalmoplegia, and peripheral face palsy, with a high mortality (>80% for infections that spread to the brain) and severe morbidity, such as eyeball exenteration and vision loss. In our hospital, a 61-year-old woman with diabetes was diagnosed with rhino-orbital-cerebral infection caused by Alternaria infectoria. Cavernous sinus thromboses (CST) were seen in surgery, pathology, and MRI. She did not respond to potent antifungal therapy until the adding of anti-thrombosis drugs. By analyzing our case, together with the ones that have been published, we realized that fungal thrombosis in the cavernous sinus is the main pathophysiological problem in ROCM that typically shows mass enhancement within the cavernous sinus in radiographic images, thrombosis with characteristics of ischemia and infarction in pathology. Anticoagulation/antithrombus therapy might be helpful in the management of ROCM if potent antifungal treatment does not have effect.

Rhinocerebral mucormycosis due to Rhizopus oryzae in a diabetic patient: a case report

Mucormycosis is an opportunistic fulminant fungal infection, which affects nose and paranasal sinuses by direct invasion or through the blood vessels mainly in diabetic and immunocompromised patients. In the present study, a rhino-orbito-cerebral mucormycosis in a 24-year-old female with diabetes mellitus as underlying disease was reported. Computed tomography (CT scan) demonstrated an increase in the soft tissue densities in the left nasal cavity, maxillary and ethmoid sinuses and destruction of the antral wall with soft tissue densities in the pterygopalatine fossa and retromaxillary fissure. In histopathology, wide ribbon-shape non-septate hyphae were seen in tissue sections stained with hematoxylin-eosin (H&E). The etiologic fungus isolated from tissue biopsy on mycological media was identified by the amplification and sequencing of the 5.8S RNA gene and of the adjacent internal transcriber spacer domains, ITS1/ITS4, as Rhizopous oryzae. Recognition of the unique patterns of this high mortality rhinocerebral fungal infection in patients with diabetes is a key to early diagnosis and successful treatment.

Cervicofacial tissue infarction in patients with acute invasive fungal sinusitis: prevalence and characteristic MR imaging findings

INTRODUCTION

Tissue infarction is known as one of the characteristic features of invasive fungal sinusitis (IFS). The purpose of this study was to investigate the prevalence and characteristic MR imaging findings of cervicofacial tissue infarction (CFTI) associated with acute IFS.

METHODS

We retrospectively reviewed MR images in 23 patients with histologically or microbiologically proven acute IFS. CFTI was defined as an area of lack of enhancement in and around the sinonasal tract on contrast-enhanced T1-weighted images. We divided CFTI into two groups, i.e., intrasinonasal and extrasinonasal. Particular attention was paid to the location of extrasinonasal CFTI and the signal intensity of CFTI on T1- and T2-weighted images. The presence of bone destruction on CT scans was also recorded.

RESULTS

CFTI was found in 17 (74%) of 23 patients. All of these 17 patients had intrasinonasal CFTI, and 13 patients also had extrasinonasal CFTI. All 13 patients with extrasinonasal CFTI died of disease directly related to IFS. Various locations were involved in the 13 patients with extrasinonasal CFTI, including the orbit (n = 8), infratemporal fossa (n = 7), intracranial cavity (n = 3), and oral cavity and/or facial soft tissue (n = 4). Various signal intensities were noted at the area of CFTI on T1- and T2-weighted images. Bone destruction was found on CT scans in only 3 of 17 patients with CFTI.

CONCLUSION

CFTI with preservation of the bony wall of the involved sinonasal tract may be a characteristic MR imaging finding of acute IFS. The mortality is very high once the lesion extends beyond the sinonasal tract.

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature

BACKGROUND

Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment.

DESIGN

Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals.

PARTICIPANTS

Fourteen patients (10 men and 4 women; age range 46-82 years).

METHODS

Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment.

MAIN OUTCOME MEASURES

Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed.

RESULTS

Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived - both had orbital exenteration, as well as antifungal drug treatment.

CONCLUSIONS

Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome.

Survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence

OBJECTIVES/HYPOTHESIS

Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.

STUDY DESIGN

Systematic review.

METHODS

Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.

RESULTS

All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.

CONCLUSIONS

The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.

LEVEL OF EVIDENCE

N/A.

Uncommon ophthalmologic disorders in intensive care unit patients

Ophthalmologic complications are frequently encountered in intensive care unit (ICU) patients (Grixti et al. Ocul Surf 2012;10(1):26-42). However, eye care is often overlooked in the critical care setting or just limited to the ocular surface because treatment is focussed on the management of organ failures. Lack of awareness about other less common intraocular sight-threatening conditions may have a devastating effect on the patient's vision. To identify specific, frequently missed uncommon ocular disorders in ICU, a literature review using the keywords "Intensive Care," "Eye care," "ITU," "ICU," "Ophthalmological disorders," "Eye disorders" was performed. The databases of CINAHL, PuBMed, EMBASE, and Cochrane library were searched. The higher quality studies are summarized in the table with statements of methodology to clarify the level of evidence. The most prevalent ophthalmologic disorders identified in critically ill subjects include exposure keratopathy, chemosis, and microbial keratitis. In addition, uncommon eye disorders reported in ICU include metastatic endogenous endophthalmitis, acute primary angle closure, ischemic optic neuropathy, pupil abnormalities, vascular occlusions, and rhino-orbital cerebral mucormycosis. Early diagnosis and effective treatment will help to prevent visual loss.

Epidemiology and clinical manifestations of mucormycosis

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. Mucormycosis has emerged as the third most common invasive mycosis in order of importance after candidiasis and aspergillosis in patients with hematological and allogeneic stem cell transplantation. Mucormycosis also remains a threat in patients with diabetes mellitus in the Western world. Furthermore, this disease is increasingly recognized in recently developed countries, such as India, mainly in patients with uncontrolled diabetes or trauma. Epidemiological data on this type of mycosis are scant. Therefore, our ability to determine the burden of disease is limited. Based on anatomic localization, mucormycosis can be classified as one of 6 forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon presentations. The underlying conditions can influence clinical presentation and outcome. This review describes the emerging epidemiology and the clinical manifestations of mucormycosis.

Mucormycosis of the hard palate masquerading as carcinoma

A growing number of medically compromised patients are encountered by dentists in their practices. Opportunistic fungal infections such as mucormycosis usually occur in immunocompromised patients but can infect healthy individuals as well. Mucormycosis is an acute opportunistic, uncommon, frequently fatal fungal infection, caused by a saprophytic fungus that belongs to the class of phycomycetes. Among the clinical differential diagnosis we can consider squamous cell carcinoma. Such cases present as chronic ulcers with raised margins causing exposure of underlying bone. There is a close histopathological resemblance between mucormycosis and aspergillosis. Microscopically, aspergillosis has septate branching hyphae, which can be distinguished from mucormycotic hyphae by a smaller width and prominent acute angulations of branching hyphae. A definitive diagnosis of mucormycosis can be made by tissue biopsy that identifies the characteristic hyphae, by positive culture or both. The culture of diseased tissue may be negative and histopathologic examination is essential for early diagnosis. Mucormycosis was long regarded as a fatal infection with poor prognosis. However with early medical and surgical management survival rates are now thought to exceed 80%. In the present case, the fungus was identified by hematoxylin and eosin stain and confirmed by Grocott's silver methenamine special staining technique. Removal of the necrotic bone, which acted as a nidus of infection, was done. Post-operatively patient was advised an obturator to prevent oronasal regurgitation. Since mucormycosis occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation.

Invasive mycoses: strategies for effective management

Effective management of invasive fungal infections (IFIs) depends on early individualized therapy that optimizes efficacy and safety. Considering the negative consequences of IFI, for some high-risk patients the potential benefits of prophylactic therapy may outweigh the risks. When using a prophylactic, empiric, or preemptive therapeutic approach, clinicians must take into account the local epidemiology, spectrum of activity, pharmacokinetic and pharmacodynamic parameters, and safety profile of different antifungal agents, together with unique host-related factors that may affect antifungal efficacy or safety. Therapeutic drug monitoring is increasingly recognized as important or necessary when employing lipophilic triazoles (itraconazole, voriconazole, posaconazole) or flucytosine. Because early diagnostics remain limited for uncommon, yet emerging opportunistic molds (e.g., Mucorales), and treatment delay is associated with increased mortality, early effective management often depends on a high index of suspicion, taking into account predisposing factors, host cues favoring mucormycosis, and local epidemiology. Antifungal options for mucormycosis are limited, and optimal management depends on a multimodal approach that includes early diagnosis/clinical suspicion, correction of underlying predisposing factors, radical debridement of affected tissues, and extended antifungal therapy. This article discusses strategies for the effective management of invasive mycoses, with a particular focus on antifungal hepatotoxicity.

Mucormycosis of the hard palate masquerading as carcinoma

A growing number of medically compromised patients are encountered by dentists in their practices. Opportunistic fungal infections such as mucormycosis usually occur in immunocompromised patients but can infect healthy individuals as well. Mucormycosis is an acute opportunistic, uncommon, frequently fatal fungal infection, caused by a saprophytic fungus that belongs to the class of phycomycetes. Among the clinical differential diagnosis we can consider squamous cell carcinoma. Such cases present as chronic ulcers with raised margins causing exposure of underlying bone. There is a close histopathological resemblance between mucormycosis and aspergillosis. Microscopically, aspergillosis has septate branching hyphae, which can be distinguished from mucormycotic hyphae by a smaller width and prominent acute angulations of branching hyphae. A definitive diagnosis of mucormycosis can be made by tissue biopsy that identifies the characteristic hyphae, by positive culture or both. The culture of diseased tissue may be negative and histopathologic examination is essential for early diagnosis. Mucormycosis was long regarded as a fatal infection with poor prognosis. However with early medical and surgical management survival rates are now thought to exceed 80%. In the present case, the fungus was identified by hematoxylin and eosin stain and confirmed by Grocott's silver methenamine special staining technique. Removal of the necrotic bone, which acted as a nidus of infection, was done. Post-operatively patient was advised an obturator to prevent oronasal regurgitation. Since mucormycosis occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation.

Comparative study of orbital involvement in invasive and non-invasive fungal sinusitis

OBJECTIVE

To investigate differences in orbital involvement in patients with invasive versus non-invasive fungal sinusitis.

METHOD

One hundred consecutive cases of fungal sinusitis were assessed clinically and by computed tomography scan to evaluate orbital involvement.

RESULTS

Clinical orbital involvement was more common in invasive (73.5 per cent) than non-invasive (12.1 per cent) fungal sinusitis (p = 0.000). Computed tomography scanning showed similar orbital involvement in both groups, except for erosion of the floor of the orbit, which was more common in patients with invasive fungal sinusitis (p = 0.01). Extra-ocular muscle enlargement (44.4 vs 4 per cent, p = 0.01) and optic atrophy (44.4 vs 0 per cent, p = 0.003) were more common in chronic than acute invasive fungal sinusitis. Four patients (16 per cent) with acute invasive fungal sinusitis had no evidence of orbital involvement on scanning, despite clinical evidence of optic atrophy.

CONCLUSION

Orbital involvement is more common in invasive than non-invasive fungal sinusitis. The difference is more evident clinically than on computed tomography scanning. Patients with acute invasive fungal sinusitis may have limited evidence of orbital involvement on scanning, despite extensive clinical disease.

Rhino-orbital-mucormycosis as a presenting manifestation of gestational diabetes mellitus

Rhino-orbital mucormycosis is an uncommon and aggressive, angioinvasive fungal infection that occurs in immunocompromised states like diabetes mellitus, chronic renal failure, hematological malignancies and deferroxamine therapy. We report a patient who presented with rhino-orbital mucormycosis at six months of gestation and was incidentally detected to have diabetes. She was successfully treated with amphotericin B and appropriate surgery. To the best of our knowledge, there is no such report in the literature.

Occlusion of the Internal Carotid Artery due to Intracranial Fungal Infection

In recent years the immunocompromised population has increased rapidly to include people with acquired immune deficiency syndrome (AIDS), drug abusers, and transplant patients. Accordingly, the incidence of intracranial fungal infection has increased. Our institution experienced 2 cases of internal carotid artery (ICA) occlusion due to invasion of the cavernous sinus by an intracranial fungal infection. The first case was a 60-year-old man who presented with headache, eye pain, conjunctival injection, right-sided diplopia, and blurred vision. Infected tissues within the frontal and ethmoid sinuses were removed via bifrontal craniotomy and endoscopic sinus surgery through the Caldwell Luc approach. The second case was a 63-year-old woman who developed right-sided facial pain after a tooth extraction. The infection was not controlled despite continuous use of antifungal agents, resulting in death from sepsis. We believe that when intracranial fungal infection is suspected in a patient with orbital symptoms and a focal neurologic deficit, immediate angiographic investigation of possible ICA occlusion is warranted. Aggressive treatment with antifungal agents is the only way to improve prognosis.

Zygomycosis in Immunocompromised non-Haematological Patients

Zygomycoses caused by fungi of the mucorales order (mucormycoses) are emerging fungal diseases with a high fatality rate. The most important risk factors include neutropenia or functional neutropenia, diabetic ketoacidosis, iron overload, major trauma, prolonged use of corticosteroids, illicit intravenous drug (ID) use, neonatal prematurity, malnourishment, and maybe a previous exposure to antifungal agents with no activity against zygomycetes, such as voriconazole and echinocandins.A high index of suspicion is crucial for the diagnosis, as prompt and appropriate management can considerably reduce morbidity and mortality. Suspicion index can be increased through recognition of the differential patterns of clinical presentation. In the non- haematological immunocompromised patients, mucormycosis can manifest in various clinical forms, depending on the underlying condition: mostly as rhino-orbital or rhino-cerebral in diabetes patients, pulmonary infection in patients with malignancy or solid organ transplantation, disseminated infection in iron overloaded or deferoxamine treated patients, cerebral - with no sinus involvement - in ID users, gastrointestinal in premature infants or malnourishment, and cutaneous after direct inoculation in immunocompetent individuals with trauma or burns.Treating a patient's underlying medical condition and reducing immunosuppression are essential to therapy. Rapid correction of metabolic abnormalities is mandatory in cases such as uncontrolled diabetes, and corticosteroids or other immunosuppressive drugs should be discontinued where feasible. AmphotericinB or its newer and less toxic lipid formulations are the drugs of choice regarding antifungal chemotherapy, while extensive surgical debridement is essential to reduce infected and necrotic tissue. A high number of cases could be prevented through measures including diabetes control programmes and proper pre- and post-surgical hygiene.

Hyperglycemic hyperosmolar state and rhino-orbital mucormycosis

Rhino-orbital mucormycosis is a fatal infection. Decompensated diabetes is the most common predisposing factor. Two male adults were admitted because of newly diagnosed diabetes with hyperglycemic hyperosmolar state and CT scan showed extensive pansinusitis and orbital inflammation. Treatment included surgical debridement and antifungal therapy. One patient died from a severe sepsis.

Fungal infections of the central nervous system in HIV-negative patients: experience from a tertiary referral center of South India

Objective:

To describe the clinical, radiological, and cerebrovascular fluid (CSF) findings and the outcome of microbiologically or histopathologically proven fungal infections of the central nervous system (CNS) in HIV-negative patients.

Methodology and Results:

We identified definite cases of CNS mycosis by screening the medical records of our institute for the period 2000–2008. The clinical and imaging details and the outcome were abstracted from the medical records and entered in a structured proforma. There were 12 patients with CNS mycosis (i.e., 2.7% of all CNS infections treated in this hospital); six (50%) had cryptococcal infection, three (25%) had mucormycosis, and two had unclassified fungal infection. Four (33%) of them had diabetes as a predisposing factor. The common presentations were meningoencephalitis (58%) and polycranial neuritis (41%). Magnetic resonance imaging revealed hydrocephalus in 41% and meningeal enhancement in 25%, as well as some unusual findings such as subdural hematoma in the bulbocervical region, carpeting lesion of the base of the skull, and enhancing lesion in the cerebellopontine angle. The CSF showed pleocytosis (66%), hypoglycorrhachia (83%), and elevated protein levels (100%). The diagnosis was confirmed by meningocortical biopsy (in three cases), paranasal sinus biopsy (in four cases), CSF culture (in three cases), India ink preparation (in four cases), or by cryptococcal polysaccharide antigen test (in three cases). Out of the ten patients for whom follow-up details were available, six patients recovered with antifungal medications (amphotericin B, 1 mg/kg/day for the minimum period of 6 weeks) and/or surgical treatment. Four patients expired (only one of them had received antifungal therapy).

Conclusions:

Most patients with CNS mycosis recover with appropriate therapy, but the diagnosis and management of these rare infections remains a challenge to clinicians.

Successful treatment of a case with rhino-orbital-cerebral mucormycosis by the combination of neurosurgical intervention and the sequential use of amphotericin B and posaconazole

Rhino-orbital-cerebral (ROC) mucormycosis is an uncommon, acute and aggressive fungal infection. It remains a challenging problem to clinicians despite aggressive debridement surgery and antifungal therapy. The authors describe a case of ROC mucormycosis with pericranial abscess occurring in a female patient with uncontrolled diabetes mellitus. The infection initially developed in the right-sided nasal sinus and later progressed through the paranasal sinuses with the invasion of the peri-orbital and frontotemporal region, due to the delayed diagnosis and treatment. Numerous non-septate hyphae of the zygomycetes were identified by a punch biopsy from the nasal cavity and by an open biopsy of the involved dura. The patient was treated successfully with extensive debridement of her necrotic skull and surrounding tissues, drainage of her pericranial abscess and antifungal therapy, including intravenous amphotericin B for 61 days and oral posaconazole for the following 26 days. She returned to a normal life and has had no recurrence since the end of her treatment 15 months ago.

Long-term posaconazole treatment and follow-up of rhino-orbital-cerebral mucormycosis in a diabetic girl

To demonstrate that the 2-yr clinical follow-up of our patient strongly suggests that long-term therapy with posaconazole (POS) is safe and beneficial in treatment and prevention of relapses of, otherwise fatal, central nervous system mucormycosis. Mucormycosis is a very rare opportunistic mycotic infection of diabetic children. We present the 30-month follow-up of a 12-yr-old girl affected by diabetic ketoacidotic coma, complicated by rhinocerebral mucormycosis and successfully treated with POS at the initial daily dose of 5 mg/kg t.i.d. with fatty food for 3 wk, followed by a daily dose of 10 mg/kg in four doses for 2 months and then 20 mg/kg/d in four doses for 16 months and in two doses for further 5 months. The previous amphotericin B, granulocyte colony-stimulating factor, hyperbaric oxygen and nasal and left maxillary sinus surgical debridement therapy was ineffective in stopping the progression of the infection to the brain. The patient improved within 10 d with reduced ocular swelling and pain, and 6 months after therapy stop, she is in good health and cultures are sterile. This article demonstrates that POS may be a useful drug in mucormycosis in children. We also strongly draw the attention to the main preventive procedure against invasive fungal infection that is the correct management of antidiabetic therapy that prevents the predisposing temporary neutrophils activity deficit, contributing to a better survival rate of diabetic children.

Endogenous mycotic endophthalmitis in an immunocompetent patient

Acute and invasive fungal infections are usually seen in immunocompromised and debilitated patients. We report a young immunocompetent 28-year-old Indian male who presented with unilateral endogenous endophthalmitis in the left eye and was managed with pars plana vitreous surgery. The polymerase chain reaction from the vitrectomy specimen tested positive for the fungal genome while the cytology examination identified aseptate hyphae with wide-angle branching, most likely suggesting Zygomycosis. A detailed systemic evaluation failed to reveal any systemic focus or predisposing factor for fungal infection. The patient had received intravenous dextrose infusions while undergoing a surgical procedure for post-traumatic hydrocele elsewhere a week prior to this episode. The patient was successfully managed with pars plana vitreous surgery along with intravitreal Amphotericin-B and oral Voriconazole.

Rhino-orbital-cerebral mucormycosis and aspergillosis: differential diagnosis and treatment

In immunocompromised patients, symptoms and the pathogen spectrum of sinusitis are frequently atypical. If progressive loss of vision occurs, an infection of the anterior skull base or nasal sinuses should be considered. We report on four patients with orbit-associated symptoms. CT-imaging revealed bony defects in sinus borders to orbits or endocranium. In all the cases immediate surgical drainage was performed because complications following sinusitis were suspected. Histopathological diagnosis revealed two cases of aspergillosis and mucormycosis. The possibility of opportunistic infections by saprophytic fungi must be taken into account in immunocompromised patients, as they may endanger both vision and survival. Immediate diagnosis and therapy are essential. Nowadays, therapeutic success can be achieved due to advances in antimicrobial therapy, hyperbaric oxygen therapy and treatment of the underlying disease. Radical procedures like orbital exenteration must be considered in all cases. The current state of diagnostics, therapy and prognosis is discussed based on these case reports and the recent literature.

Rhino-orbital-cerebral mucormycosis with different cerebral involvements: infarct, hemorrhage, and ophthalmoplegia

Rhino-orbital-cerebral mucormycosis is a rare but often fatal opportunistic necrotizing infection of the sinuses, orbit, and brain caused by saprophytic fungi. It usually develops in patients with diabetes or immune system deficiency. In this study, imaging features in 3 patients with rhino-orbital-cerebral mucormycosis who presented with various symptoms and different cerebral involvements are discussed. Headache, blurred vision, fever, painful ophthalmoplegia, and cranial nerve involvement were among the clinical findings. Computed tomography and magnetic resonance imaging are the best imaging methods for assessing the extent of this disease. Relatively typical but nonspecific characteristics are bone destruction, vascular invasion, and central hypointensity in the paranasal sinuses or an intracranial mass that is revealed by T(2)-weighted magnetic resonance imaging. Imaging findings include cavernous sinus involvement, cerebral infarct, and intracerebral hemorrhage. Because of the invasive and fulminant nature of rhino-orbital-cerebral mucormycosis, successful treatment seems to be based on early diagnosis and on the management of underlying immunologic problems.

Orbital Inflammatory Disease

OBJECTIVES

To familiarize rheumatologists and internists with the signs, symptoms, and management of orbital inflammatory disease (OID).

METHODS

A comprehensive literature review related to OID was performed and reported from the perspectives of rheumatology, ophthalmology, and radiology.

RESULTS

OID is a general term encompassing inflammatory diseases that affect some or all of the structures contained within the orbit external to the globe. Orbital involvement as a part of the initial symptom complex is not uncommon for systemic diseases such as Graves' disease, Wegener's granulomatosis, and sarcoidosis. The management of these and other causes of OID, such as idiopathic orbital inflammation (formerly known as "orbital pseudotumor"), orbital myositis, and Tolosa-Hunt syndrome frequently involves systemic immunosuppression. Before immunosuppression is considered, however, infectious and malignant causes of inflammation must be ruled out.

DISCUSSION

Rheumatologists should be familiar with the differential diagnosis of OID and often need to assist colleagues in ophthalmology and internal medicine with the management of this group of diseases.

Orbital Exenteration: A Dilemma in Mucormycosis Presented with Orbital Apex Syndrome

Background

Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic, fungal paranasal sinus infection. The most critical decision in the management of rhino-orbital mucormycosis is whether the orbit should be exenterated. The literature fails to provide a broad base of information of how physicians determine the need for exenteration in daily practice. The decision for exenteration often depends on the judgment of the treating otolaryngologist. The authors report their experience and outline that orbital exenteration may not be mandatory in all cases of rhino-orbital mucormycosis.

Methods

The medical records from Celal Bayar University Medical Faculty Department of Otorhinolaryngology/Head and Neck Surgery were retrospectively searched from 1995 to 2007 for three cases with rhino-orbital mucormycosis, treated without orbital exenteration.

Results

All patients with rhino-orbital mucormycosis who were treated without exenteration survived.

Conclusion

The favorable outcome was attributable to rapid correction of the underlying medical condition; wide local excision and debridement of all involved and devitalized sinonasal and periorbital tissue, while establishing adequate sinus and orbital drainage; daily endoscopic assessment with multiple sinus debridement when necessary; daily irrigation of the involved areas; and high-dose i.v. amphotericin B.

Rhinocerebral zygomycosis: an increasingly frequent challenge: update and favorable outcomes in two cases

Zygomycosis or mucormycosis is an increasingly frequent life-threatening infection caused by opportunistic fungal organisms of the class Zygomycetes. The pathognomonic feature is the presence of invasive aseptate mycelia that are larger than other filamentous fungi with the hyphae exhibiting right angle and haphazard branching. Usually classified as rhinocerebral, disseminated, and cutaneous types, this classification serves as important predictor of pathogenesis and outcome. These occur mostly in immunosuppressed patients including individuals with diabetes (43% exhibit the rhino-cerebral form) and patients with organ transplants and hematologic malignancies. Without early aggressive treatment, the disease follows a dismal and fatal course. The prognosis has not shown any appreciable change in the past 40 years with a stagnant mortality rate of 44%. We present 2 cases of rhinocerebral zygomycosis (RCZ), in a 58-year-old male and a 63-year-old female; both were poorly controlled diabetic patients with maxillary lesions suggestive of osteomyelitis. The patients were leading a near normal life with minimal discomfort or signs and symptoms of underlying mycosis. Most of the health care professionals treating these patients often overlooked the disease or recommended inadequate therapy. Despite long delays and inadequate initial therapy these patients survived with little outward morbidity. The prognosis for this condition may therefore be considered less dire than previously thought.

Infections in Diabetes Mellitus and Hyperglycemia

Infections in diabetes mellitus are relatively more common and serious. Diabetic patients run the risk of acute metabolic decompensation during infections, and conversely patients with metabolic decompensation are at higher risk of certain invasive infections. Tight glycemic control is of paramount importance during acute infected or high stress state. Infections in diabetic patients result in extended hospital stays and additional financial burden. Given the risks of not alleviating the metabolic dysregulation and the benefits of decent glycemic control, it is necessary that besides antimicrobial therapy, equal emphasis be placed on intensified glycemic control.

Zygomycosis: an uncommon cause for peripheral facial palsy in diabetes

Mucormycosis is an emerging fungal infection with a high rate of mortality. Diabetic and immuno-compromised patients are the most frequent hosts. We report a case of rhino-orbito-cerebral mucormycosis revealed by facial palsy in a diabetic, immuno-compromised patient with difficult life conditions. He received intravenous antifungal treatment (amphotericin B) and early surgical debridement and completely recovered with no recurrence after 3 months of follow-up. Physicians should be aware of such atypical clinical presentations due to the need for early appropriate combined medical and surgical management to improve disease recovery and prognosis.

Invasive zygomycosis: update on pathogenesis, clinical manifestations, and management

Zygomycosis is an increasingly common infection in immunocompromised patients. Advances in the understanding of Zygomycetes pathobiology and the introduction of new drugs with improved activity and tolerability for treatment of zygomycosis have improved the prospects of effectively controlling this devastating infection. Further reductions in mortality will require improved diagnostic and novel therapeutic approaches for this group of aggressive opportunistic molds.

Posaconazole for treatment of refractory invasive fungal disease

Invasive fungal infections are usually associated with immunocompromised states About 40-60% of these patients are refractory to standard antifungal therapy We describe the effect of posaconazole in the treatment of a 12 years-old girl with uncontrolled diabetes mellitus with life-threatening cerebral mucor mycosis and a 4 year old girl boy with chronic granulomatous disease presenting with invasive Aspergillus nidulans infection.

Upper-extremity mucormycosis infections in immunocompetent patients

PURPOSE

Mucormycosis can produce an aggressive and sometimes fatal soft tissue infection seen most commonly in immunocompromised individuals. Eradication consists of surgical resection and antifungal chemotherapy. Knowledge regarding infectious mucormycosis in the upper extremity has been limited to case reports involving mainly immunocompromised individuals. The purpose of this study was to identify risk factors for the development of mucormycosis infections within the upper extremity in immunocompetent individuals and to evaluate the effectiveness of the present therapies.

METHODS

A 12-year retrospective review of all fungal infections involving the upper extremity was conducted in our institution. Seven immunocompetent patients with infectious cutaneous mucormycosis of the upper extremity were identified from 223 primary upper-extremity fungal infections.

RESULTS

In the 7 patients 3 infections resulted from heavy soil contamination after motor vehicle collisions and 4 resulted from conveyor belt injuries in agricultural facilities. All patients had considerable upper-extremity soft tissue loss and 6 of the 7 patients had upper-extremity fractures or dislocations. Patients had an average of 10 surgical debridements. Four infections resulted in amputations: 1 partial hand amputation, 1 below the elbow, 1 above the elbow, and 1 at the glenohumeral joint.

CONCLUSIONS

Mucormycosis can produce limb-threatening infections in an immunocompetent host. Hand surgeons must have suspicion of such infections in patients with grossly contaminated open wounds.

Zygomycosis: the re-emerging fungal infection

Invasive fungal infections are major medical complications in immunocompromised patients. The recent rise in the incidence of cancer and the increased use of newer medical treatment modalities, including organ transplantations, have resulted in growing numbers of highly immunosuppressed individuals. Although aspergillosis and candidiasis are among the most common invasive mycoses in such patients, there is evidence that the incidence of infectious diseases caused by Zygomycetes has risen significantly over the past decade. Patients with diabetes, malignancies, solid organ or bone marrow transplants, or iron overload and those receiving immunosuppressive agents, deferoxamine therapy, or broad-spectrum antimicrobial drugs are at highest risk for zygomycosis. This review details the emergence and importance of zygomycosis in current clinical practice and its manifestations and management. The etiologic species, pathogenesis and risk factors for zygomycosis are reviewed and updated. The clinical spectrum of zygomycosis is now broader, and it can be difficult to distinguish between mucormycosis and enthomophthoramycosis, both of which can manifest as disease ranging from a superficial infection to an angioinvasive infection with high mortality. Finally, the three-part treatment strategy (antifungal drugs, surgery, control of underlying diseases) is reviewed. Lipid formulations of amphotericin B are the antifungal agents of choice for treatment of zygomycosis. A novel antifungal triazole, posaconazole, has been developed and may become approved for treatment of zygomycosis. The clinical experience with adjunctive treatments like colony-stimulating factors, interferon-gamma, and hyperbaric oxygen therapy is still limited.