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

Skull base infections, their complications, and management

OBJECTIVE

Our review aims to summarize the current literature on skull base infections (SBIs) and retrospectively analyze any such cases encountered at our institution.

DESIGN

A literature search was conducted using online databases PubMed, MEDLINE, and ResearchGate with the terms "skull base osteomyelitis," "temporal bone osteomyelitis," "skull base infections," "necrotizing otitis media," and "SBO". References from the resulting manuscripts were reviewed for relevant articles. A search of our electronic health records using the same key terms was also performed to identify patients with a tissue biopsy-confirmed diagnosis of skull base infections. Patients with an indeterminate diagnosis or inaccessible/poor imaging were excluded.

SETTING

A level one trauma and major tertiary academic medical center.

PARTICIPANTS

All patients treated at the University of California Davis Health System with a confirmed diagnosis of skull base infections from January 2005 to November 2020.

MAIN OUTCOME MEASURES

Imaging results, symptoms, treatment, morbidity, and mortality.

RESULTS

Our literature search yielded 59 articles ranging from 1982 to 2021. A retrospective search of our electronic health records identified two cases of skull base infections.

CONCLUSION

Skull base infections have no pathognomonic findings. A multimodal approach with computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine is necessary to characterize the disease process in addition to a biopsy for definitive diagnosis. Other diagnoses can mimic SBI on imaging, such as nasopharyngeal carcinoma and inflammatory pseudotumor. Culture-guided antimicrobial treatment and surgery are mainstay therapies. Other adjuvant strategies currently lack the robust evidence necessary to characterize their risks and benefits.

Post-COVID Fungal Osteomyelitis-Another Killer

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been sweeping across the globe as a pandemic. Based on a retrospective analysis of SARS data from worldwide, it is summarized that the fungal co-infections associated with global COVID-19 might be missed or misdiagnosed. Along with, we report case series of fungal infections in the maxilla and in the orbit, who were successfully treated for covid-19 and are on regular follow-up.

Orbital mucormycosis in immunocompetent children; review of risk factors, diagnosis, and treatment approach

BACKGROUND

Orbital mucormycosis is a rare but potentially severe and troublesome invasive fungal infection that could be occurred even in healthy individuals. The initial clinical presentation is similar to bacterial pre-septal or septal cellulitis, especially in early stages.

CASE PRESENTATION

Herein, we describe the successful management of a series of five cases presenting with orbital mucormycosis in previously healthy children.

CONCLUSIONS

Orbital mucormycosis is extremely rare in healthy children and maybe life-threatening when diagnosis delayed given a similar clinical presentation with bacterial septal cellulitis. Intravenous antifungal therapy with amphotericin B and timely surgical drainage is live-saving.

Maxillary Fungal Osteomyelitis: A Review of Literature and Report of a Rare Case

Fungal osteomyelitis is a life-threatening and seldom seen opportunistic infection. It is commonly an affectation of the nose and paranasal sinuses within the orofacial region. It is an aggressive infection that needs to be addressed promptly to prevent fatal consequences. Here, we present a case of a 62-year-old female who presented with complaints of pain and pus discharge from the extraction socket of the left maxillary 23, 24, 25, 26 teeth. She had a history of uncontrolled diabetes mellitus. On further investigation, using diagnostic and Interventional aids, a final diagnosis of maxillary fungal osteomyelitis was made. The infective fungal agents were a mixture of Mucorales and Aspergillus species. A review of all literatures on the subject in the past 13 years using different search engines showed that craniofacial fungal infections with primary maxillary involvement are a rare phenomenon. The primary aim of reporting this case, therefore, is to highlight its rarity, presentation, management and most importantly the outcome of management.

An Emergent Entity: Indolent Mucormycosis of the Paranasal Sinuses. A Multicenter Study

Introduction  Indolent or chronic mucormycosis is a rare entity that affects both immunosuppressed and immunocompetent individuals. Additionally, its clinical evolution is nonspecific and there is no standardized treatment for this condition.

Objective  To describe the clinical characteristics and management of patients with indolent mucormycosis.

Methods  In the project of study with chart review in the Interinstitutional secondary care centers, patients with evidence of indolent mucormycosis, defined as pathological confirmation of nasal/paranasal sinus mucormycosis for more than 1 month, were included. All patients underwent complete laboratory workup, imaging studies, surgical treatment and adequate follow-up. No evidence of disease status was defined when patient had subsequent biopsies with no evidence of mucormycosis.

Results  We included seven patients, three female and four male subjects. The mean age was 53.14 years. Four patients were immunosuppressed and three immunocompetent. Among the immunosuppressed patients three had diabetes and one had dermatomyositis. The symptoms were nonspecific: facial pain/headache, mucoid discharge and cacosmia were the ones most frequently reported. Maxillary sinus involvement was present in all patients. Two immunosuppressed subjects received amphotericin. Posaconazole was the only treatment in one immunosuppressed patient. All immunocompetent patients had single paranasal sinus disease and received only surgical treatment. All patients are alive and free of disease.

Conclusion  Indolent mucormycosis is a new and emerging clinical entity in immunosuppressed and immunocompetent patients. Single paranasal sinus disease is a frequent presentation and should not be overlooked as a differential diagnosis in these patients. Immunocompetent patients should only be treated surgically.

Treatment of Rhinocerebral Mucormycosis by Combination of Endoscopic Sinus Debridement and Amphotericin B

Rhinocerebral mucormycosis (RCM) is an aggressive fungal infection with a high mortality rate. It frequently develops in patients with uncontrolled diabetes mellitus or immunocompromised patients. RCM typically presents in a rapidly fulminant manner with headache, fever, mucosal necrosis, and ophthalmic symptoms. Although the definitive diagnosis is achieved by histopathological examination, computed tomography (CT) scanning and magnetic resonance (MR) are the best imaging procedures in early diagnosis to assess the extent of the disease.

The "black evil" affecting patients with diabetes: a case of rhino orbito cerebral mucormycosis causing Garcin syndrome

Mucormycosis is a life-threatening infection affecting patients with diabetes. It is an angioinvasive disease often resistant to treatment with a debilitating course and high mortality. Here, we report a case of a 45 year old woman with type 2 diabetes mellitus who presented to us with history of right-sided ptosis and facial palsy, and subsequently developed loss of vision and palatal palsy. She was in diabetic ketoacidosis. Nervous system examination revealed involvement of right second, third, fourth, sixth, seventh, ninth, and tenth cranial nerves, suggestive of Garcin syndrome. The hard palate had been eroded with formation of black eschar. Computed tomography of paranasal sinuses revealed right maxillary and ethmoid sinusitis, with spread of inflammation to infratemporal fossa and parapharynygeal neck spaces. Debridement of sinus mucosa was done, and culture of the same yielded growth of rhizopus species. Histopathological examination of the tissue showed angioinvasion and fungal hyphae suggestive of mucormycosis. She was treated with amphotericin B, posaconazole, and periodic nasal sinus debridement, but her general condition worsened after 8 weeks due to secondary sepsis and she succumbed to death.

Nasal NK/T cell lymphoma presents with long-term nasal blockage and fever: a rare case report and literature review

NK/T cell lymphoma (NKTCL) is a common disease which is a threat to human health. Nasal NKTCL is a rare but serious type of systemic lymphoma because of its high mortality rate and serious complications. In this case report, we describe a male who presented with nasal blockage in the right side, a fever of one month duration and a soy-like, painless and gradually increasing mass in the right submandibular region due to nasal NKTCL. The patient had no significant medical history and the initial clinical symptoms were nasal blockage. Contrast computed tomography showed that the nasopharyngeal mucosa was thickened and that the celiac and retroperitoneal lymphaden was intumescent. Finally a biopsy, guided by nasal endoscopy and examined using flow cytometry confirmed a diagnosis of NKTCL. Nasal NKTCL is rare and has no unique characteristics at first presentation, such as epidemiology and obvious clinical manifestation. As no effective therapy is currently available for this disease, early diagnosis and therapy of nasal NKTCL remains challenging.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND

This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults.

METHODS

Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed.

RESULTS

A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%).

CONCLUSIONS

Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

Fungal Sinusitis

Fungal sinusitis is characterized into invasive and noninvasive forms. The invasive variety is further classified into acute, chronic and granulomatous forms; and the noninvasive variety into fungus ball and allergic fungal sinusitis. Each of these different forms has a unique radiologic appearance. The clinicopathologic and corresponding radiologic spectrum and differences in treatment strategies of fungal sinusitis make it an important diagnosis for clinicians and radiologists to always consider. This is particularly true of invasive fungal sinusitis, which typically affects immuno compromised patients and is associated with significant morbidity and mortality. Early diagnosis allows initiation of appropriate treatment strategies resulting in favorable outcome.

Prosthetic rehabilitation of acquired maxillary defects secondary to mucormycosis: clinical cases

Maxillary necrosis can occur due to bacterial infections such as osteomyelitis, viral infections, such as herpes zoster or fungal infections, such as mucormycosis, aspergillosis etc. Mucormycosis is an opportunistic fungal infection, which mainly infects immunocompromised patients. Once the maxilla is involved, surgical resection and debridement of the necrosed areas can result in extensive maxillary defects. The clinician is to face many a challenge in order to replace not only the missing teeth, but also the lost soft tissues and bone, including hard palate and alveolar ridges. The prosthesis (Obturator) lacks a bony base and the lost structures of the posterior palatal seal area compromise retention of the prosthesis. Furthermore, the post surgical soft tissues are scarred and tense, which exert strong dislodging forces. The present article describes the prosthetic rehabilitation of maxillary necrosis secondary to mucormycosis in two cases, one completely edentulous and the other partially edentulous.

Mucormycosis in maxilla: Rehabilitation of facial defects using interim removable prostheses: A clinical case report

Maxilla is one of the facial bones with rich vascular supply. Necrosis of maxillary bone is rare and may occur due to infection, trauma and rare metabolic disorders. Maxilla is essential bone forming the roof of oral cavity. Mucormycosis is one of the most common fungal infection, which affects maxilla especially in diabetes and immunocompromised patients. We report a case of maxillary necrosis due to mucormycosis in an uncontrolled diabetic patient. Early diagnosis and prompt treatment can reduce the mortality and morbidity of this lethal fungal infection.

Indolent mucormycosis of the paranasal sinus in immunocompetent patients: are antifungal drugs needed?

OBJECTIVE

To report the clinical characteristics and treatment outcomes of indolent paranasal mucormycosis in immunocompetent individuals.

MATERIALS AND METHODS

A retrospective review of four immunocompetent patients with indolent mucormycosis of the paranasal sinus managed by endoscopic sinus surgery only was performed. One year of regular follow up comprised angled endoscopy and repeated paranasal sinus computed tomography three months after surgery.

RESULTS

Clinical symptoms were non-specific. Pre-operative paranasal sinus computed tomography showed opacification of the unilateral maxillary sinus with focal calcification but without bony destruction or extension to the orbit or cranium. All patients underwent endoscopic sinus surgery without administration of antifungal agents. There was no recurrence on regular clinical and radiological follow up.

CONCLUSION

For indolent paranasal mucormycosis in immunocompetent patients, endoscopic sinus surgery can be the treatment of choice, and the administration of antifungal drugs may not be necessary.

Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies

BACKGROUND

Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

DISCUSSION

Key conclusions reached were: rhinosinusitis is preferred to sinusitis; acute invasive fungal rhinosinusitis is preferred to fulminant, or necrotizing and should refer to disease of <4 weeks duration in immunocompromised patients; both chronic invasive rhinosinusitis and granulomatous rhinosinusitis were useful terms encompassing locally invasive disease over at least 3 months duration, with differing pathology and clinical settings; fungal ball of the sinus is preferred to either mycetoma or aspergilloma of the sinuses; localized fungal colonization of nasal or paranasal mucosa should be introduced to refer to localized infection visualized endoscopically; eosinophilic mucin is preferred to allergic mucin; and allergic fungal rhinosinusitis (AFRS), eosinophilic fungal rhinosinusitis, and eosinophilic mucin rhinosinusitis (EMRS) are imprecise and require better definition. In particular, to implicate fungi (as in AFRS and EMRS), hyphae must be visualized in eosinophilic mucin, but this is often not processed or examined carefully enough by histologists, reducing the universality of the disease classification. A schema for subclassifying these entities, including aspirin-exacerbated rhinosinusitis, is proposed allowing an overlap in histopathological features, and with granulomatous, chronic invasive, and other forms of rhinosinusitis. Recommendations for future research avenues were also identified.

Rhinocerebral mucormycosis in patients without predisposing medical conditions: a review of the literature

Rhinocerebral mucormycosis is a rare disease, affecting almost exclusively patients with known predisposing conditions such as diabetes mellitus, immunocompromised status, haemochromatosis or major trauma. Subsequent to a case of rhinocerebral mucormycosis in a 78-year-old woman without any known risk factor, we reviewed the published English-language literature and found an additional 72 cases. Reviewing all the published case series of mucormycosis involving any site, the proportion of apparently normal hosts among cases of rhinocerebral mucormycosis was found to be 9.06% (95% confidence interval 6.7-11.8). These findings suggest that rhinocerebral mucormycosis in patients without known predisposing factors is more prevalent than was previously believed.

The rise of an opportunistic infection called "Invasive Zygomycosis"

Invasive zygomycosis is a devastating fungal infection seen mostly in immune-compromised patients. We present a case of a 48-year old diabetic man, with aplastic anemia, who developed severe pulmonary mucormycosis that led to his rapid demise despite early diagnosis and treatment with liposomal amphotericin B. We also conducted an extensive review of the pathogenesis of invasive zygomycosis, its history, predisposing factors, clinical aspects, diagnostic modalities, treatment options, morbidity and mortality.

Epidemiology and Medical Mycology of Fungal Rhinosinusitis

Fungal rhinosinusitis (FRS) refers to a spectrum of disease ranging from benign colonization of the nose and sinuses by pathogenic fungi to acute invasive and fatal inflammation extending to the orbit and brain. FRS is classified into two categories: invasive and noninvasive. Invasive FRS may again be subcategorized into acute invasive (fulminant) FRS, granulomatous invasive FRS, and chronic invasive FRS; while noninvasive FRS is subcategorized into localized fungal colonization, sinus fungal ball and eosinophil related FRS (including allergic fungal rhinosinusitis, eosinophilic fungal rhinosinusitis). This classification is not without controversies, and intermediate and semi-invasive forms may also exist in particular patients. Acute invasive FRS is an increasingly common disease worldwide among the immunocompromised patients and caused most frequently by Rhizopus oryzae, and Aspergillus spp. Granulomatous invasive FRS has mostly been reported from Sudan, India, and Pakistan and is characterized by noncaseating granuloma formation, vascular proliferation, vasculitis, perivascular fibrosis, sparse hyphae in tissue, and isolation of A. flavus from sinus contents. Chronic invasive FRS is an emerging entity occurring commonly in diabetics and patients on corticosteroid therapy, and is characterized by dense accumulation of hyphae, occasional presence of vascular invasion, sparse inflammatory reaction, involvement of local structures, and isolation of A. fumigatus. While localized fungal colonization describes the most benign of all fungal sinusitis in the superficial nasal crusts, sinus fungal ball is a dense mycetoma like aggregate of fungal hyphae in diseased sinuses. Common in southern Europe, especially France, majority of them are sterile on culture while 30-50% may yield Aspergillus spp. The definitions and pathogenesis of the group of syndromes in eosinophil related FRS (AFRS, EFRS) are contentious and a matter of intense research among otolaryngologists, pathologists, immunologists and microbiologists. While dematiaceous fungi are the foremost initiators of these syndromes in the west, Aspergillus flavus is the predominant pathogen in India and the Middle-East.

Invasive mucormycosis of the maxillary sinus: extensive destruction with an indolent presentation

BACKGROUND

Mucormycosis (zygomycosis) is a rare, aggressive, invasive fungal infection that usually afflicts immunosuppressed patients. Indolent presentations are rare, especially in the setting of immune suppression.

METHODS

Case report and review of the pertinent English-language literature.

CASE REPORT

A 64-year-old male patient with diabetes mellitus and rheumatoid arthritis, treated chronically with infliximab, presented with toothache, headache, and right facial numbness. Therapy with intravenous glucocorticoids and antibiotics resulted in transitory improvement before his referral to a tertiary-care center, where imaging studies and biopsy revealed rhinocerebral mucormycosis. Four weeks after initial presentation, a radical right maxillectomy, followed by long-term therapy with amphotericin B lipid complex, resulted in clinical improvement. Five reconstructive procedures were required to obliterate the facial defect and restore contour. Although biopsies during the reconstructive procedures revealed persistent fungal colonization, there was no clinical recurrence during nearly five years of followup.

CONCLUSIONS

Indolent rhinocerebral mucormycosis is rare and is seldom survived by immunosuppressed patients. Multimodal therapy with surgical debridement and antifungal chemotherapy is required for an optimal outcome. Discontinuance of immunosuppressive therapy, if possible, is a cornerstone of management.

Paranasal mucormycosis: Unusual presentation in otherwise healthy child

Mucormycosis is the fungal infection usually involving immunocompromized individuals. In this article we present a case of mucomycosis affecting a 12-year-old healthy boy who was treated by endoscopic surgical technique. Postoperatively patient was put on Amphotericin B nasal douching and oral Itraconazole. There was no recurrence till the last follow up at six month postoperatively.

Localized bilateral paranasal mucormycosis: a case in an immunocompetent patient

Mucormycosis of the nasal cavity and paranasal sinuses is an uncommon opportunistic fungal infection, which often has an aggressive, life-threatening course. Patients who have this condition are generally diabetic or immunosuppressed. However, mucormycosis can also occur in immunocompetent individuals. The most effective treatment consists of reversal of the source of immunocompromise, immediate surgical debridement and administration of systemic amphotericin B. No consensus has been reached regarding the appropriate surgical treatment or the total dose of amphotericin B. We present the case of a patient suffering from localized bilateral paranasal mucormycosis who was treated by means of endoscopic sinus surgery and administration of systemic amphotericin B. We suggest that endoscopic sinus surgery is the choice of treatment for localized paranasal mucormycosis in an immunocompetent patient, and that the total dose of amphotericin B can be determined by the extent of disease and the postoperative endoscopic findings.

Detection of villous conidia of Conidiobolus coronatus in a blood sample by scanning electron microscopy investigation

Conidiobolus coronatus is a major insect pathogen belonging to the fungal order Entomophthorales, causing a rare subcutaneous infection of the nasofacial region, resulting in swelling of predominantly the nose, mouth, and perinasal tissue. Later in the course of the infection firm, painless, subcutaneous nodules develop that are attached to the underlying tissues but not to the skin. No morphological studies are available in the literature on the morphology of C. coronatus in vivo and all morphological studies have been conducted on in vitro cultures. Here the authors report on the ultrastructural pathology as seen with a scanning electron microscope (SEM) of villous conidia of C. coronatus, detected in a 37-year-old woman who presented to the casualty department at Pretoria Academic Hospital, South Africa with left-sided facial pain and headache. The diagnosis of C. coronatus was confirmed by LightCycler real-time flourescence PCR technique. Research shows that typically diagnosis of the pathogen is established only on histological examination, and in over 85% of cases cultures for the causative organism is negative. This pathogen has not previously been found in a blood sample and the authors present for the first time the morphology of C. coronatus in blood using the SEM.

Rhino-orbitocerebral entomophthoramycosis

Conidiobolus coronatus is recognized as a human pathogen causing subcutaneous fungal infection of the face in immunocompetent patients. The disease process is usually benign. We report, what we believe to be the first case of intracranial extension of C. coronatus producing rhino-orbitocerebral syndrome, and subsequent dissemination of C. coronatus in an immunocompetent patient.

Epidemiology and outcome of zygomycosis: a review of 929 reported cases

BACKGROUND

Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease.

METHODS

We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described.

RESULTS

The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively).

CONCLUSIONS

Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.

Rhinocerebral mucormycosis: An analysis of probable mode of spread and its implication in an early diagnosis and treatment

The study was done in two parts:Analysis of CT scan findings of 17 cases of mucormycosis to determine paranasal sinus, orbital and intra-cranial involvement.Cadaveric dissections of the ethmoid complex anatomy to correlate the probable mode of spread. Ethmoidal sinus was found to be the most commonly involved. The disease probably appears first here, spreads to orbit through the lamina papyracea and then through the retro-orbital region, intra-cranially. Our aim would be to diagnose the disease at the stage of ethmoid involvement. In immuno-compromised patients, if headache, peri- or retro-orbital pain or blood stained nasal discharge occur; a CT scan of the paranasal sinuses and a nasal endoscopy with biopsy from anterior ethmoids, if this area shows pathology then CT scan must be performed. If this is positive for mucormycosis, surgical debridement of the involved sinuses is to be done and Amphotericin B as intra-venous infusion and treatment of underlying condition is started.

Chronic rhizopus invasive fungal rhinosinusitis in an immunocompetent host

HYPOTHESIS

Rhizopus species may cause chronic invasive fungal rhinosinusitis in an immunocompetent host.

STUDY DESIGN

Individual case report.

METHODS

Review of inpatient and outpatient records, radiographic studies, pathologic examination, and microbiology of the presented case. Review of the literature.

RESULTS

Rhizopus species may be the cause of chronic invasive fungal rhinosinusitis in an immunocompetent host and result in intracranial extension.

Rhinoorbital Mucormycosis Secondary to Rhizopus Oryzae: A Case Report and Literature Review

Mucormycosis is a form of fulminant invasive fungal infection of the sinonasal tract that often extends to the orbit, brain, palate, and skin. It is caused by members of the order Mucorales, and it is considered to be the most fatal fungal infection known to man because it is rapidly disseminated by the blood vessels. It is most commonly associated with diabetic ketoacidosis, hematologic malignancies, acquired immunodeficiency syndrome, and immunosuppressive therapy. This rare opportunistic infection exists in many forms, the most common of which is rhinocerebral mucormycosis. Treatment includes aggressive surgical debridement of the necrotic tissue combined with systemic antifungal therapy. In this case report, we describe the successful management of rhinoorbital mucormycosis, a subtype of the rhinocerebral variety, secondary to Rhizopus oryzae that developed in a patient with lymphoma. We review the diagnostic work-up and discuss the literature with respect to the presentation, pathophysiology, management, and outcome of the disease.

Usefulness of frozen section in rhinocerebral mucormycosis diagnosis and management

AIMS

Rhinocerebral mucormycosis (RCM) is a well-described fulminant fungal infection that presents acutely in patients with ketoacidosis and immunosuppression. Very early diagnosis, established with the demonstration of characterised hyphae in tissues, greatly improves the prognosis of RCM. In this regard, the specificity and the sensitivity of frozen section for the diagnosis and the surgical debridement of RCM were evaluated in this study.

METHODS AND RESULTS

Frozen section was performed for the diagnosis (six of seven cases) and surgical treatment (three of seven cases) of RCM. In all cases, diagnosis was made by frozen section and confirmed by histological examination. Frozen section allowed radical surgical excision of infected tissue. In all cases, invasive, broad-based non-septated hyphae with branching at right angles were well demonstrated on toluidine blue staining. Cultures were positive for Rhizopus oryzae in three of seven cases. Outcome was favourable for five of seven patients and two patients died after the diagnosis.

CONCLUSIONS

Frozen section is a specific and sensitive method to make both a quick initial diagnosis of RCM and to successfully eradicate the tissue infected by organisms belonging to the order Mucorales.

Rhinocerebral mucormycosis in a boy with recurrent acute lymphoblastic leukemia: long-term survival with systemic antifungal treatment

Rhinocerebral mucormycosis is rare in hematologic malignancies and usually leads to death within weeks. In contrast, chronic rhinocerebral mucormycosis takes a slowly progressive course and has not been reported in hematologic malignancies in children so far. The authors report the long-term survival of a boy with rhinocerebral mucormycosis in a relapse of acute lymphoblastic leukemia after allogeneic cord blood transplantation. The disease started acutely but took a chronic course thereafter. No surgical debridement was performed because of extensive involvement of the sinuses, orbits, and cerebrum. His long-term survival of 15 months is attributed to the long-range administration of liposomal amphotericin B, early neutrophil recovery, and slow progression of the relapsing acute lymphoblastic leukemia.

Rhinocerebral mucormycosis in the era of lipid-based amphotericin B: case report and literature review

Rhinocerebral mucormycosis (RCM) is an invasive fungal infection that necessitates, in most cases, aggressive surgical debridement and high cumulative, often nephrotoxic doses of amphotericin B. A 50-year-old woman with RCM was treated successfully with amphotericin B lipid complex as primary therapy. The patient previously had displayed progressive intracranial involvement and rising serum creatinine levels while receiving the conventional (nonlipid) form of amphotericin B. A literature review identified only a few cases where systemic antifungal therapy was administered, with minimal or no surgery. Our case further supports that amphotericin B lipid complex can be used as primary therapy in selected patients with RCM, without the need for surgical exenteration.

Longterm survival in acute rhinocerebral mucormycosis with giant cell arteritis and foreign body granulomas

A case of rhinocerebral mucormycosis occurring in a 41-year-old man with insulin-treated diabetes mellitus is reported. Microscopically, biopsy samples obtained from the left ethmoid and middle turbinate sinuses contained fungi that formed mycotic granulomas associated with multinucleate giant cell arteritis. The multinucleate giant cells contained broad, infrequently septate hyphase consistent with mucormycosis. The patient received surgical debridement with extenteration of the left orbit, and intravenous liposome-encapsulated amphotericin B. After 12 months, examination of the patient revealed complete healing. Multinucleate giant cell granulomas and arteritis are only exceptionally associated with rhinocerebral mucormycosis, but these histologic findings may be correlated with a progressive disease with better prognosis.

Ten years' experience in zygomycosis at a tertiary care centre in India

OBJECTIVE

To define the spectrum of zygomycosis due to mucorales in an Indian scenario.

METHODS

One-hundred and twenty-nine patients with zygomycosis due to mucorales diagnosed at the Postgraduate Institute of Medical Education and Research, Chandigarh, India during 1990-99, were retrospectively analysed regarding the sites of involvement, underlying disease, species of fungi isolated and outcome of therapy.

RESULTS

Higher prevalence rate (19.4%) was observed in 1999. Rhino-orbito-cerebral type (44.2%) was the commonest presentation followed by cutaneous (15.5%) and renal (14.0%) involvement. Disseminated zygomycosis was seen in 11.6% patients. Pulmonary and gastrointestinal zygomycosis were diagnosed in 10.1% and 4.7% patients, respectively. Uncontrolled diabetes mellitus (in 50% of cases) was the significant risk factor in rhino-orbito-cerebral type [odds ratio (OR), 9.3; P<or=0.001) and breach of skin (in 40% cases) in cutaneous zygomycosis (OR, 6.9; P<or=0.01). However, a considerable number of 22 (22.9%) patients were apparently healthy hosts in this series. Forty-five patients (34.9%) of this series were diagnosed only at post-mortem. Among 47 patients where culture was attempted, mucorales were isolated from 25 patients with Rhizopus arrhizus (11 patients) and Apophysomyces elegans (eight patients) as the predominant isolates. Adequate therapy could be provided in 33 patients. A combination of aggressive surgical debridement of necrotic tissue and amphotericin-B was found to be the best treatment protocol as 81.3% patients treated with surgical debridement and amphotericin-B were cured, compared with 46.7% patients treated with amphotericin-B alone.

CONCLUSION

The study highlights the importance of increased awareness for early diagnosis of zygomycosis and aggressive management. The large number of cases in apparently healthy hosts and increased isolation of A. elegans in the present series are important characteristics of this disease in India and requires further evaluation.

Mucormycosis of the nose and paranasal sinuses

Rhinocerebral mucormycosis is an invasive fungal infection initiated in the paranasal sinuses that frequently progresses to orbital and brain involvement. If recognized early, involvement is limited to the nasal cavity and paranasal sinuses. Diabetics in poor control are at greatest risk, however, any immunocompromised individual may be infected. The mainstays of therapy are reversal of immunosuppression, systemic amphortericin B, and surgical débridement. Survival has improved dramatically, yet deaths still occur if the infection is not recognized and not treated early in its course or if the source of immunocompromise is not reversible. Several case examples illustrate the clinical course of this unusual, but potentially fatal, fungal infection. Taxonomy, clinical presentation, diagnosis, and management of mucormycosis of the paranasal sinuses are reviewed in detail.

Long-term survival of a patient with invasive cranial base rhinocerebral mucormycosis treated with combined endovascular, surgical, and medical therapies: case report

OBJECTIVE

Rhinocerebral mucormycosis is a clinical syndrome resulting from an opportunistic infection caused by a fungus of the order Mucorales. The prognosis of rhinocerebral mucormycosis, once considered uniformly fatal, remains poor. Even with early diagnosis and aggressive surgical and medical therapy, the mortality rate is high. We present a patient with rhinocerebral mucormycosis involving the paranasal sinuses and cranial base who experienced long-term survival after multimodality treatment. Clinical characteristics of the disease are discussed, and the literature is reviewed.

CLINICAL PRESENTATION

A 24-year-old diabetic man presented with invasive rhinocerebral mucormycosis involving the paranasal sinuses, right middle fossa, and right cavernous sinus.

INTERVENTION

The patient underwent endovascular sacrifice of the involved carotid artery and radical resection of the cranial base, including exenteration of the cavernous sinus. Reconstruction with a local muscle flap was performed. He continued to receive intravenous and intrathecal administration of antibiotics.

CONCLUSION

Long-term survival with invasive rhinocerebral mucormycosis is rare, but possible, with aggressive multimodality treatment, including carotid sacrifice for en bloc resection of the pathology, when indicated.

Long-term survival in rhinocerebral mucormycosis. Case report

Mucormycosis refers to a group of rapidly progressive infections caused by fungi belonging to the order Mucorales. Infection most often develops in individuals with immunological or metabolic compromise, although patients without underlying abnormalities have been affected. Specific clinical manifestations are associated with various predisposing factors. Rhinocerebral mucormycosis is the most common form and most frequently develops in individuals with poorly controlled diabetes mellitus. The extent of anatomical involvement and clinical course are unpredictable, depending on the intrinsic factors of the host. Over the past 20 years the prognosis for patients with rhinocerebral mucormycosis, once considered to be a uniformly fatal disease, has improved. Coordinated medical and surgical treatment, including rapid diagnosis, the advent of systemic antifungal agents, aggressive surgical debridement, and control of the underlying disease process, have been credited with its successful management. The range of survival rates recorded with the regimen of combined therapies is wide because the number of patients reported is limited and anatomical involvement is diverse. Survival with intracerebral abscess is rare. The authors describe the successful management of a patient who developed a bifrontal fungal abscess during treatment for rhinocerebral mucormycosis associated with ketoacidosis and diabetes mellitus. The patient remains without radiographic or clinical evidence of infection more than 2 years after treatment. The authors review the characteristic clinical, radiographic, and pathological features of previously reported infections and emphasize the importance of early detection and aggressive treatment in the management of this frequently fulminant and fatal disease.