Fatal fulminant myocarditis caused by disseminated mucormycosis

Infectious factors in myocarditis: a comprehensive review of common and rare pathogens

BACKGROUND

Myocarditis is a significant health threat today, with infectious agents being the most common cause. Accurate diagnosis of the etiology of infectious myocarditis is crucial for effective treatment.

MAIN BODY

Infectious myocarditis can be caused by viruses, prokaryotes, parasites, and fungi. Viral infections are typically the primary cause. However, some rare opportunistic pathogens can also damage heart muscle cells in patients with immunodeficiencies, neoplasms and those who have undergone heart surgery.

CONCLUSIONS

This article reviews research on common and rare pathogens of infectious myocarditis, emphasizing the complexity of its etiology, with the aim of helping clinicians make an accurate diagnosis of infectious myocarditis.

Fulminant myocarditis and pulmonary cavity lesion induced by disseminated mucormycosis in a chronic hemodialysis patient: Report of an autopsied case

Mucormycosis is a rare fungal infection occurring in the immunocompromised host. It is difficult to diagnose, and its cardiac involvement is extremely rare. Here, we report a 64-year-old Japanese man with a 5-year history of hemodialysis with disseminated mucormycosis causing fulminant myocarditis and pulmonary necrosis under glucocorticoid use. Two months before, he had received an implantable cardioverter defibrillator and started to take amiodarone for recurrent ventricular arrhythmias due to hypertensive cardiomyopathy. He developed amiodarone-induced interstitial pneumonia and then received glucocorticoid therapy. Although the interstitial pneumonia partially improved, a lung cavitary lesion developed in the upper right lobe. Antibiotics had no effect, and serologic tests, blood and sputum cultures and bronchoalveolar lavage fluid were all negative for infectious pathogens. Eventually, he died of fulminant myocarditis. Autopsy revealed disseminated mucormycosis with vascular invasion and fungal thrombi, hemorrhage and infarction in lung (cavity lesion), heart (severe myocarditis), brain, thyroid and subcutaneous tissue around the implantable cardioverter defibrillator. The lung cavitary lesion was the only clinical finding suggestive of mucormycosis before autopsy. When an immunocompromised patient shows a progressive lung cavity lesion, the possibility of mucormycosis should be considered so that a broad-spectrum antifungal agent can be empirically administered in a timely fashion.

Acute Cardiac Failure due to Intra-Atrial Mass Caused by Zygomycetes in an Immunocompromised Paediatric Patient

Cardiac zygomycosis can be a critical condition with sudden onset of severe congestive heart failure followed by severe hemodynamic deterioration. We report a fatal course of disseminated fungal infection with a massive intra-atrial thrombosis caused by a zygomycete, in a five year old boy treated for acute lymphoblastic leukaemia. In addition, we discuss the literature concerning infections caused by zygomycetes involving the heart. Prognosis is poor. A high index of suspicion and an aggressive diagnostic and therapeutic approach with the prompt start of preemptive antifungal therapy are key factors to improve outcome.

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.

Fungal infections of the heart: A clinicopathologic study of 50 autopsy cases

Cardiac fungal infection (CFI) is relatively uncommon, but its incidence is increasing. It is associated with a grim prognosis, but some CFI patients can survive given an early diagnosis and aggressive therapy. To clarify the clinicopathologic features of CFI, a retrospective autopsy study was conducted. Among a total of 4396 autopsy cases collected over a 33-year period (1973-2005), 50 CFI patients (1.1%) were selected and studied clinicopathologically. The study subjects were 32 males and 18 females with a mean age of 65.5 years. Underlying diseases for CFI included solid malignant neoplasms (n=23), hematologic disorders (n=10), chronic renal diseases (n=7), liver diseases (n=5), diabetes mellitus (n=5), and other miscellaneous ailments. Antibiotics were given to 47 patients, while corticosteroids, antineoplastic drugs, and antifungal agents were used for 21, 12, and 12 patients, respectively. None of the patients was diagnosed to have CFI antemortem. Most patients (n=45) demonstrated multi-organ fungal infections with myocardial involvement. Causative pathogens were Candida (n=36), Aspergillus (n=9), Mucor (n=4), and Cryptococcus (n=1). Comparisons between previous CFIs (1973-1989) and recent CFIs (1990-2005) revealed an increasing proportion of non-candidal CFIs (p=0.004) in the latter. Our results point to the clinical importance of defining diagnostic criteria and therapeutic strategies for CFIs, especially for non-candidal CFIs.

Cardiac mucormycosis in a child with severe aplastic anemia: a case report

Mucormycosis is an uncommon, severe, life-threatening fungal infection in the immunocompromised host. Mucormycosis with aplastic anemia is seen rarely. Only a few cases of cardiac mucormycosis with aplastic anemia have been reported in the literature. The authors present a case with severe aplastic anemia that did not respond to classic and immunosuppressive treatment for disease and developing invasive cardiac mucormycosis despite empiric treatment for febrile neutropenia.

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.