Localized bilateral paranasal mucormycosis: a case in an immunocompetent patient

Thamnostylum piriforme, a novel etiological agent of superficial mycosis

Fungi are opportunistic eukaryotic entities often taking advantage of susceptibilities offered by a host due to its immunocompromised status, changed microbiome, or ruptured physical barriers and eventually cause infections. They either invade the skin superficially or are deep-seated. Superficial mycosis affects the skin, hair, and nails inhabiting the outermost layer, stratum corneum. In the present study, we report a case of superficial mycosis (onychomycosis in particular) in a 45-year-old immunocompetent man who was an ex-defense personnel and presently serving as a security guard at the University of Jammu, District Jammu, Jammu and Kashmir, India. The infection evolved 17 years ago and negatively affected the quality of life of the patient. For the identification of the causal agent, direct microscopy, cultural, micro-morphological, molecular characterization (ITS sequencing), and phylogenetic analysis were taken into account. A mucoralean fungal species, Thamnostylum piriforme, was isolated from the fingernails (left hand) of the investigated patient, which represents a new global report as the causal agent of superficial mycosis. In vitro antifungal susceptibility testing showed T. piriforme sensitivity to itraconazole, amphotericin B and ketoconazole while resistance to fluconazole. Careful selection of optimal therapy for fungal infection based primarily on correct identification and antifungal susceptibility testing could provide effective results during treatment against these opportunistic human fungal pathogens.

Invasive Fungal Infections in the Paediatric Intensive Care Unit: A Hong Kong Study

INTRODUCTION

Invasive fungal infections (IFI) cause significant mortality and morbidity in the Paediatric Intensive Care Unit (PICU). Early recognition and prompt treatment of invasive fungal infections are important. This article reviewed the mortality and morbidity of IFIs in the PICU of Hong Kong Children's Hospital.

METHODS

A retrospective review of all PICU admissions from April 2019 to May 2021 was performed. The following data were retrieved: age, gender, diagnosis, comorbidity, clinical manifestation, type of fungus, duration of stay at PICU, absolute neutrophil count, use of immunosuppressive therapy, presence of central venous catheter and use of total parental nutrition. The primary outcomes were the incidence and mortality of IFIs among PICU patients. The secondary outcomes were risk factors for developing IFI in PICU and clinical course of IFIs. Numerical variables were compared between groups by Mann-Whitney U test and categorical variables by Fisher's exact test.

RESULTS

There were 692 PICU admissions over the study period from April 2019 to May 2021. The crude mortality was 3% (n=24 death cases) in the PICU. Fourteen patients (2%) fulfilling the criteria for IFIs were identified using hospital electronic record system and according to PICU documentation. Eight of these 14 patients (57%) had hematological malignancy, 2 (17%) had solid tumours and 4 had non-oncological conditions. Eight (57%) patients were neutropenic with absolute neutrophil count less than 1x 109 at diagnosis of IFI. Ten (71%) had received immunosuppressive therapy including steroid, cyclosporin A, Mycophenolate mofetil (MMF), Sirolimus or tacrolimus. 12 (86%) had had central venous catheter. Eight (57%) were on parenteral nutrition. IFIs due to Rhizopus or Aspergillus infection (5/14), or in post-haematopoietic stem cell transplant patients (5/14) were associated with non-survival (p = 0.031).

CONCLUSION

All patients with IFIs managed in the PICU had haemato-oncology diseases or were recipients of stem cell transplantation. IFIs with Rhizopus or Aspergillus as a group were associated with high mortality in the PICU. Awareness of this pathology with prompt diagnosis and treatment may improve the outcome of these infections and reduce the mortality.

A Unique Case of Intracranial Mucormycosis Following an Assault

Intracranial mucormycosis is a very unusual presentation of an infection after a depressed skull fracture due to an assault. Only sporadic cases have been reported in the literature previously. A 30-year-old male with a traumatic brain injury following an assault, status-post debridement and elevation of a depressed skull fracture, was discharged home several weeks postoperatively. A CT scan of the head with contrast was obtained due to mental status changes and revealed an enhancing ring-shaped lesion in the right frontal lobe consistent with a brain abscess. The patient was taken to the operating room for image-guided excisional biopsy of the lesion, with pathology revealing mucormycosis. 

Successful treatment of invasive rhinopulmonary mucormycosis with an indolent presentation by combined medical and surgical therapy

In many cases of mucormycosis, immediate surgical treatments are necessary because of its fulminant course and destructive characteristics in an immunocompromised patient. However, a chronic indolent type is also observed in a healthy group of people. We experienced rhinomucormycosis in a 56-year-old woman with diabetes who previously had pulmonary mucormycosis. She was treated successfully through endoscopic sinus surgery and nasal irrigation with antifungal agent. Herein, we report the clinical courses and symptoms of this patient with literature review.

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.

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.