Systemic zygomycosis

Isolated Renal Mucormycosis Simulating a Renal Neoplasm in a Patient With the Acquired Immunodeficiency Syndrome

We report the case of a terminally ill patient with the acquired immunodeficiency syndrome who presented with a tender enlarged renal mass that simulated a renal neoplasm. A needle biopsy of the kidney revealed ischemic necrosis, vascular destruc tion, and fungal forms consistent with infection by the Zygomycetes family. Subse quently, autopsy confirmed this diagnosis and established that the kidney was the sole site of this fungal infection. Since fungal infections of the kidney simulating a renal tumor have not previously been described in acquired immunodeficiency syndrome, this report expands the list of lesions produced by opportunistic infections arising in a setting of human immunodeficiency virus-induced immunosuppression. Int J Surg Pathol 2(2):163-168, 1994

[Disseminated mucormycosis in immunocompetent patients: A disease that also exists]

Mucormycosis is usually an acute angioinvasive infections, which leads to non-suppurative necrosis and significant tissue damage. It represents 1.6% of all the invasive fungal infections and predominates in immunosuppressed patients with risk factors. Incidence has been significantly increased even in immunocompetent patients. Due to finding a case of disseminated mucormycosis caused by Rhizomucor pusillus in a young immunocompetent patient, a systematic review was carried out of reported cases in PubMed of mucormycosis in immunocompetent adults according to the main anatomic locations, and especially in disseminated cases. A review of the main risk factors and pathogenicity, clinical manifestations, techniques of early diagnosis, current treatment options, and prognosis is presented. Taxonomy and classification of the genus Mucor has also been reviewed.

[Mixed invasive fungal infection due to Rhizomucor pusillus and Aspergillus niger in an immunocompetent patient]

BACKGROUND

Mucormycosis infections are rare in immunocompetent patients, and very few cases of mucormycosis associated with aspergillosis in non-haematological patients have been reported.

CASE REPORT

A 17-year-old male, immunocompetent and without any previously known risk factors, was admitted to hospital due to a seizure episode 11 days after a motorcycle accident. He had a complicated clinical course as he had a mixed invasive fungal infection with pulmonary involvement due to Aspergillus niger and disseminated mucormycosis due to Rhizomucor pusillus (histopathological and microbiological diagnosis in several non-contiguous sites). He was treated with liposomal amphotericin B for 7 weeks (total cumulative dose >10 g) and required several surgical operations. The patient survived and was discharged from ICU after 5 months and multiple complications.

CONCLUSIONS

Treatment with liposomal amphotericin B and aggressive surgical management achieved the eradication of a mixed invasive fungal infection. However, we emphasise the need to maintain a higher level of clinical suspicion and to perform microbiological techniques for early diagnosis of invasive fungal infections in non-immunocompromised patients, in order to prevent spread of the disease and the poor prognosis associated with it.

Skin mucormycosis presenting as an erythema-nodosum-like rash in a renal transplant recipient: a case report

Introduction

Cutaneous mucormycosis is a rare entity related to kidney transplantation. It usually presents with ecthyma-like lesions and black necrotic cellulitis. We report an unusual case of primary cutaneous mucormycosis presenting as erythema-nodosum-like lesions in a woman who had received a renal transplant.

Case presentation

A 49-year-old woman with diabetes received a living-unrelated kidney transplant. Her clinical course was uneventful for the first six months after transplantation. She then developed multiple, painful, erythema-nodosum-like lesions on her right leg and thigh following an episode of minor trauma. Mucormycosis was diagnosed by skin biopsy. Microscopic examination also showed panniculitis. The patient was treated successfully with amphotericin B and surgical resection. To our knowledge, this is the first description of primary cutaneous mucormycosis with erythema-nodosum-like lesions and panniculitis after renal transplantation.

Conclusion

Cutaneous mucormycosis should be considered in the differential diagnosis when a kidney transplant recipient develops erythema-nodosum-like lesions with panniculitis.

Renal zygomycosis: an under-diagnosed cause of acute renal failure

BACKGROUND

Invasive zygomycosis (mucormycosis) occurs predominantly in immunocompromised patients in whom it carries a grave prognosis. While renal involvement is not so uncommon in disseminated infection, isolated renal zygomycosis is rare.

METHODS AND RESULTS

Forty-five patients with systemic zygomycosis were seen over a 12-year period from January 1986 to December 1997. Among these, 18 had renal involvement, nine with disseminated disease and nine with isolated renal zygomycosis. No underlying predisposing disease was identified in the majority of patients (72%). Renal involvement was confirmed at autopsy in 13 and by ante-mortem renal biopsy in five patients. The infection involved one kidney in five patients and was bilateral in the remaining. The manifestations included fever, flank pain, haematuria and pyuria with evidence of enlarged non-functioning kidneys on computerised tomography (CT). Of those with bilateral disease, 12 (92.3%) had anuric acute renal failure. Anti-fungal therapy was given to six patients (amphotericin B in mean total dose of 1.1 g) and of these only two with unilateral disease who also underwent nephrectomy survived while all the other 16 died.

CONCLUSION

This study shows that renal zygomycosis has emerged as a cause of acute renal failure in the last decade since no patient with renal involvement was identified at our centre prior to 1986 even though autopsies have been done regularly in patients dying of unknown causes. Bilateral renal zygomycosis should be suspected in any patient who presents with haematuria, flank pain and otherwise unexplained anuric renal failure. Characteristic CT findings and an early renal biopsy can confirm the diagnosis and help in effective management of this serious disease.

Invasive pulmonary mucormycosis with rupture of the thoracic aorta

We report an acute myelogenous leukemia patient with mucormycosis who died of massive hemoptysis during antifungal therapy. The diagnosis was made postmortem and autopsy revealed that the pulmonary nodule consisting of mucorales protruded over the luminal surface of the aorta. Microscopic examination showed the invasion of mucor hyphae into the wall of the aortic arch. Surgical treatment may be indicated for patients with pulmonary mucormycosis refractory to amphotericin B therapy.

Nosocomial zygomycotic post-surgical necrotizing fasciitis in a healthy adult caused by Apophysomyces elegans in south India

Necrotizing fasciitis caused by the zygomycete Apophysomyces elegans of the anterior abdominal wall of a young healthy woman following a lower segment caesarean section is reported. Early clinical diagnosis and laboratory identification followed by appropriate management involving extensive tissue debridement and adequate doses of amphotericin B were eventually successful in controlling the infection and saving her life.

In vitro susceptibility to 9 antifungal agents of 14 strains of Zygomycetes isolated from clinical specimens

Fourteen clinical isolates of Zygomycetes were tested for their in vitro susceptibility to nine antifungal agents. Susceptibility assessment was performed using a microtiter broth dilution method. Synthetic broth with YNB and glucose was used for 5-fluorocytosine and BHI broth for all the other antimycotics. Amphotericin B exhibited the strongest activity against all isolates tested. MIC values of other two polyenes--nystatin and pimaricin--ranged within the susceptibility limits, with a little pronounced higher activity of pimaricin. The isolates of the genus Absidia and Syncephalastrum were well sensitive to all antimycotics with the exception of 5-fluorocytosine and naftifine. A very weak or zero growth inhibitory effect against all members of the genera Mucor and Rhizopus was found in azoles, 5-fluorocytosine and naftifine.

Renal mucormycosis: computerized tomographic findings and their diagnostic significance

Isolated renal involvement by mucormycosis has been reported rarely in immunocompromised individuals. We describe four patients with mucormycosis confined to the kidneys, three of whom did not exhibit any predisposing factors. Only one patient had acute viral hepatitis with fulminant hepatic failure as the preceding disease. Two patients presented with oliguric renal failure of undetermined etiology and investigations revealed bilateral extensive involvement of the kidneys. Computerized tomography showed diffuse enlargement of the kidneys and multiple low-density areas. Treatment included systemic amphotericin B therapy in all four patients and nephrectomy in three patients. Two patients recovered completely. Our experience emphasizes the need for a high index of suspicion and recognition of computed tomographic scan appearances for making a prompt diagnosis. Early surgical intervention and systemic antifungal therapy are necessary for survival in this life-threatening condition.

Zygomycotic necrotizing fasciitis caused by Apophysomyces elegans

A case of necrotizing fasciitis of the anterior abdominal wall caused by the zygomycete Apophysomyces elegans in a healthy male following inguinal herniorrhaphy is reported. The portal of entry of the fungus into the incised skin and subcutaneous tissues was probably through either contaminated surgical sutures or postoperative surgical dressings. Broad, aseptate fungal hyphae were seen in the necrosed tissues with an associated necrotizing vasculitis. Extensive tissue debridements and a low dose of amphotericin B were not successful in controlling the rapid invasion of the tissues by the fungus.

Granulomatous pulmonary zygomycosis in a patient without underlying illness. Computed tomographic appearances and treatment by pneumonectomy

Pulmonary zygomycosis rarely occurs in the absence of underlying disease. We report a patient with granulomatous pulmonary zygomycosis without underlying disease who presented with a pulmonary mass. We present the computed tomographic findings that we believe have not been described previously. We also report the successful treatment by pneumonectomy.

Endobronchial zygomycosis

Pulmonary zygomycosis is an uncommon opportunistic fungal infection. Diabetics have a tendency to develop major airway lesions. This can lead to invasion of the airway wall and hilar vessels with infarction and severe haemoptysis. Aggressive early surgery appears to offer the best chance of recovery.

Mucormycosis in patients with renal failure

Nine fatal cases of systemic mucormycosis observed in association with renal failure are described. Four patients were hospitalized for chronic renal failure as a consequence of chronic glomerulonephritis, myeloma kidney, chronic pyelonephritis, and polycystic kidney disease, respectively; and five patients presented with acute renal failure. The underlying causes in three of these five patients were gentamycin nephrotoxicity, acute gastroenteritis, and allograft rejection, respectively, and in the remaining two, acute renal failure was the result of extensive renal vascular and parenchymal invasion by mucor hyphae. Tissue invasion with mucormycosis was documented during life in two patients and at autopsy in seven patients. The infection was disseminated in five patients, and isolated pulmonary and rhinocerebral involvement occurred in two patients each. Our observations have shown that patients with renal failure are prone to develop mucormycosis, which carries a grave prognosis if therapy is not instituted in time.

Meningitis caused by Absidia corymbifera

A 56-year-old man developed mucormycotic meningitis caused by Absidia corymbifera and which followed a penetrating head injury. Antibodies to it were detected in the cerebrospinal fluid at titres higher than those found in the serum, thereby suggesting local production of antibody in the subarachnoid space.

Endobronchial zygomycosis

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Disseminated mucormycosis presenting with acute renal failure

An unusual presentation of disseminated mucormycosis as acute renal failure in a patient without any predisposing condition, is reported. The diagnosis was established at autopsy.

Myocardial infarction caused by cardiac disease in disseminated zygomycosis

A case of disseminated zygomycosis is described, in which myocardial infarction rather than coincident coronary or heart disease was seen at necropsy. As zygomycosis is an opportunistic fungal infection, which tends to invade blood vessels, thereby causing thrombosis and infarction, it is surprising that cardiac disease is unusual and that premortem evidence of such disease has only rarely been reported.