Mucormycosis-changing status

Antimicrobial Activity of Tea and Agarwood Leaf Extracts Against Multidrug-Resistant Microbes

Emerging multidrug-resistant (MDR) strains are the main challenges to the progression of new drug discovery. To diminish infectious disease-causing pathogens, new antibiotics are required while the drying pipeline of potent antibiotics is adding to the severity. Plant secondary metabolites or phytochemicals including alkaloids, phenols, flavonoids, and terpenes have successfully demonstrated their inhibitory potential against the drug-resistant pathogens. In quest of potential phytochemicals, we selected tea (Camellia sinensis) and agarwood (Aquilaria malaccensis) leaves for antimicrobial activity. Fresh tea leaves were collected in three varieties, namely, BT-6, BT-7, and BT-8, including green tea (nonfermented tea), black tea (fully fermented tea), and agarwood leaves collected from Sylhet region of Bangladesh. This study is aimed at analyzing the phytochemical constituency and antimicrobial activity of tea and agarwood leaf extracts and analyzing if there is a combined effect or synergistic activity against multidrug-resistant pathogens. The antimicrobial activity of tea and agarwood leaf extracts was analyzed against MDR pathogenic bacteria and fungus. Qualitative and quantitative phytochemical constituency profiling of these six leaf extracts was evaluated, and preliminary screening exhibited that most of the leaves contained diverse groups of metabolites (alkaloids, tannin, flavonoids, glycosides, saponins, etc.). The highest amounts of TPC (total phenolic content) (110.16 ± 0.48 μg/mg) were found in BT-7 in ethanol extracts, and BT-8 in methanol extracts possessed the highest (128.1 ± 0.43 μg/mg) TFC (total flavonoid content). Notably, green tea showed remarkable results in TPC and TFC. In antioxidant scavenging activity, BT-7 and green tea showed significant IC50 values which were 13.23 and 20.75 mg/mL, respectively. In antimicrobial assays, both 50 μL of each tea and agarwood leaf extract antimicrobial activities were examined against 50 μL of each bacterial and fungal culture. In synergistic activity, 50 μL of each type of leaf extracts was poured over the commercial antibiotics to evaluate their synergism, additive, or antagonism activity against the multidrug-resistant pathogens. In the antimicrobial activity test, green tea showed a maximum diameter (22.0 ± 1.1 mm) zone of inhibition against Klebsiella pneumoniae whereas BT-8 showed 22.0 ± 2.5 mm against Pseudomonas aeruginosa. Indeed, fresh tea BT-6 and BT-7 both showed remarkable zone of inhibition against the selected microbes including Gram-negative and Gram-positive bacteria. Besides, leaf extract also showed antimicrobial activity against pathogenic fungus Mucor circinelloides. Aiming to increase antibiotic resistance efficacy, synergistic activities were evaluated among leaf extracts and antibiotics against the selected pathogens where synergism, antagonism, and additive results were noted. Combination of BT-8 extracts with antibiotics (ceftiofur) showed the highest synergism nearly 36 mm of the zone of inhibition against Escherichia coli. Additionally, green tea with gentamicin and erythromycin also showed remarkable synergism 35 and 33 mm against Mucor circinelloides and E. coli, respectively. Tea and agarwood leaves grown in Bangladesh possess high antioxidant activity, promising antibacterial and antifungal activity, thus might provide a potential source for drug discovery.

Fatal invasive gastric mucormycosis: Two case reports

Mucormycosis is a fungal infection affecting most commonly immunocompromised patients. Hereby, we report two cases: the first one is about a 61-year-old female with diabetes who presented with vomiting. The upper gastrointestinal endoscopy showed a budding grayish process which corresponded to an invasive mucormycosis in histology. As laboratory tests showed renal dysfunction, conventional amphotericin B was started at low doses since liposomal form was unavailable in Tunisia. Evolution was marked by a worsening of renal function leading to drug therapy withdrawal. Total gastrectomy was delayed because of a pulmonary embolism and was practiced 2 months later. The patient passed away 10 days after surgery. The second patient was a 59-year-old man who presented with vomiting and fast worsening of general state. At admission, he had a septic shock. Explorations revealed an invasive gastric mucormycosis. He died few days after admission. Thus, prompt diagnosis of mucormycosis and rapid initiation of treatment based on amphotericin B and surgical debridement is necessary to improve prognosis.

A fatal case of disseminated mucormycosis in an immunocompetent patient post traumatic injury

Mucormycosis, is an invasive infection caused by fungi. Mainly it affects patients with immunosuppressive conditions but can occur in immuncompetent host in specific situation such us direct skin inoculation by traumatic injury. We present a 56-year-old patient who hospitalized due to left orbital cellulitis and necrotizing fasciitis post traumatic injury. A diagnosis of invasive mucormycosis was established by tissue histopathology and culture. Despite daily surgical debridement and amphotericin B, the infection disseminated to central nervous system led to fatal outcome. We conclude that mucormycosis can disseminate in immunocompetent population and leads to death.

Primary Cutaneous Mucormycosis in a Trauma Patient with Morel-Lavallée Lesion

Mucormycosis is an aggressive fungal infection caused by zygomycetes from the order of Mucorales. Immunocompromised patients or patients with comorbidities are susceptible to this infection. There are many forms of mucormycosis such as rhino-orbito-cerebral, cutaneous, gastrointestinal, and pulmonary. Cutaneous mucormycosis is rare in trauma patients with no comorbidities. Morel-Lavallée lesions are rare degloving injuries in trauma patients. We report a case of cutaneous mucormycosis in a trauma patient with the Morel-Lavallée lesions.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8

Rhinocerebral mucormycosis: the disease spectrum in 27 patients

The variable forms of clinical complaints, findings and time interval of presentation in 27 cases of mucormycosis have been described, which were encountered over a span of 8 years. The previous concept about this fungal infection attacking chronic, debilitated, immunocompromised patients does not appear to hold true. Seven of the 27 patients (22.2%) did not reveal any predisposing factors and their outcome of 42.9% survival seems to be poorer than the total outcome (66.7%). 'Chronic form' of disease presentation, the definition of which is still not delineated, was encountered in four patients (14.8%). Again, the outcome was not significantly different from the total survival. Burr-hole tap of an intracranial abscess revealing mucor in a 2-month-old infant has been described. Even in the present era, extranasal exenteration of sinuses along with disfiguring orbital exenteration is required to ensure satisfactory surgical debridement. Control of the underlying predisposing illness, along with the aggressive surgical debridement and the parenteral administration of amphotericin B, remains the treatment essentials even today.

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.

Primary cutaneous mucormycosis: guide to surgical management

Mucormycosis is the most acute, fulminate, and fatal of all fungal infections in humans. It presents most frequently in immunocompromised patients, but can occur in healthy patients in the presence of often-insignificant trauma. Surgical management of primary cutaneous mucormycosis is almost always required. Case reports of surgical treatment for primary cutaneous mucormycosis are reported in the literature; however, the extent of debridement required for cure is unclear and no uniform plan of treatment has been suggested. To date, no clinical guidelines exist to assist the clinician in the surgical management of this disease. This article reviews the literature, reports on two clinical cases, and submits clinical guidelines designed to assist the clinician in the surgical management of primary cutaneous mucormycosis. Because of the infrequent and potentially fatal nature of the diagnosis, a high index of suspicion and a low threshold for wound biopsy must be maintained. Wound cultures are grossly inadequate and should not be relied on for a false sense of security. It is recommended that, for the early diagnosis of cutaneous mucormycosis, chemotherapy and surgical debridement of grossly necrotic tissue be performed at the earliest possible time. The debrided wound is monitored for the resolution of surrounding erythema and induration before definitive reconstruction. In the case of delayed diagnosis and/or advanced or rapidly progressive disease, surgical debridement of all involved tissue, in addition to chemotherapy, is warranted.

Rhinocerebral mucormycosis diagnosis by aspiration cytology

Rhinocerebral mucormycosis is a rapidly progressing, often fatal fungal infection that occurs commonly in diabetics and immunocompromised individuals. We present 2 cases of rhinocerebral mucormycosis with a paranasal mass. One patient had an intracranial extension. Nasal scrapings and fine-needle aspiration cytology (FNAC) of the paranasal masses showed fungal hyphae morphologically resembling Mucor. Surgical material showed features of mucormycosis. FNAC and scrape smears can give a conclusive diagnosis of mucormycosis, and the patient can be treated with appropriate antifungal therapy and surgical debridement. Preoperative cytology is an effective technique to establish a diagnosis of mucormycosis and obviates the need for a preoperative biopsy.

Fungal diseases of the paranasal sinuses

Fungal diseases of the paranasal sinuses can be categorized into the invasive and noninvasive varieties. The invasive form has been classified as acute fulminant fungal sinusitis, granulomatous invasive fungal sinusitis, and chronic invasive fungal sinusitis. The noninvasive form can be classified as the fungus ball and the allergic fungal sinusitis. The following review discusses the various types of fungal sinusitis with a special emphasis on the CT and MR imaging features.

Zygomycosis in HIV-positive patients: a review of the literature

The literature on zygomycotic infection in HIV-positive patients is reviewed. A total of 28 patients have been reported. The risk factor for HIV infection was known in 22 of these and was sexual transmission in only six patients and intravenous (i.v.) drug use in 16 (73%). In the latter group, it is likely that i.v. drug injection was the entry route of the zygomycotic infection. The most prevalent clinical presentations of zygomycosis in the i.v. drug-using HIV-positive patients were cerebral, cutaneoarticular and renal (accounting for 88% of presentations in total). These presentations were much less common (18%) in a cohort of 116 patients belonging to the conventional risk groups for zygomycosis (HIV negative and no i.v. drug use). The isolated cerebral localization is the typical presentation of zygomycosis in HIV-negative i.v. drug users.

Mucormycosis: experience with 10 patients

Rhinocerebral mucormycosis is a fulminating, devastating fungal disease, usually associated with debilitating diseases such as diabetes mellitus, leukaemia and immunosuppressive conditions. Ten patients with this rare disease have been treated over the past 14 years at the Beilinson Medical Centre. Nine patients had an underlying debilitating disease and one patient had latent diabetes mellitus which was diagnosed only after presentation of mucormycosis. Only two of the 10 patients survived. Early aggressive surgical debridement, together with amphotericin B and correction of underlying metabolic acidosis were found to be important factors associated with survival.

Infectious emergencies in patients with diabetes mellitus

Although it remains controversial as to whether diabetics have an overall increased incidence of infection as compared to nondiabetics, several potentially life-threatening infections do appear to be uniquely associated with diabetes. These infections generally occur in older diabetics with less than optimal glucose control. For each entity, selected symptoms and signs may suggest the diagnosis but confirmation of via tissue biopsy with culture and histopathology or radiography is usually necessary. Management typically require both antimicrobial treatment and surgery.

Zygomycosis orbital apex syndrome in association with a solitary lung carcinoma

We describe a patient who presented with orbital apex syndrome. Sphenoidectomy and biopsy revealed invasive zygomycosis. The patient had no obvious risk factors for the development of zygomycosis, but was subsequently found to have a solitary, occult lung carcinoma. The unusual clinical features of this case are discussed, and the English language literature on zygomycoses in patients with solid tumours is reviewed. Possible predisposing factors are discussed.

Isolated cerebral mucormycosis: case report and therapeutic considerations

Cerebral mucormycosis (without associated involvement of and invasion from the nasal sinuses and turbinates) is an extremely rare opportunistic infection of the central nervous system. We report the case of an intravenous drug abuser (who was negative for the human immunodeficiency virus) who presented with hemiparesis on the right side, slurred speech, altered mental status, and an unsteady gait. Imaging studies revealed a large left-side basal ganglia lesion. A stereotactic biopsy obtained a tissue sample that revealed wide, nonseptated hyphal fragments with granulomatous inflammation. The patient was treated with 3 gm of amphotericin B during a 5-month period. The patient had no residual neurological dysfunction after treatment. Open surgical resection was not employed. This case suggests that stereotactic biopsy followed by long-term amphotericin B therapy, in lieu of open surgical resection, represents a viable treatment option for this rare disorder.

Cutaneous mucormycosis resembling superficial granulomatous pyoderma in an immunocompetent host

Primary cutaneous mucormycosis is uncommon and occurs mainly in immunosuppressed or diabetic patients or after localized trauma. We report a case of cutaneous mucormycosis in an immunocompetent man in whom no definite precipitating factors could be identified; initially, superficial granulomatous pyoderma was suspected clinically. The lesion was successfully treated with debridement, local wound care, parenteral administration of amphotericin B, and ultimately by surgical excision and split-thickness skin grafting.

Pulmonary mucormycosis with fatal massive hemoptysis

A case of pulmonary mucormycosis in a 57-year-old woman with acute promyelocytic leukemia (APL) who died of massive hemoptysis is reported. Chest radiography revealed changes that began with a small focal infiltration and progressed to a large round nodule with cavity formation. Postmortem examination showed the nodule to be composed mainly of infarcted lung tissue with saprophytic growth of Mucor. An adjacent proximal branch of the left pulmonary artery was thrombosed with mucoraceous hyphae, and it had ruptured into the cavitary space around the necrotic tissue and then into a conducting bronchus. In general, both fatal massive hemoptysis and cavity formation are rare in pulmonary mucormycosis. In our present case, the histological findings suggested that both phenomena were closely related to the pulmonary infarction caused by Mucor invasion of the pulmonary artery.

Post-traumatic abdominal mucormycosis

Gastrointestinal mucormycosis, an opportunistic fungal infection, is a rare complication of trauma. We report on four patients who developed this frequently fatal condition after delayed treatment of intra-abdominal sepsis and discuss the aetiology, diagnosis and management of the disease.

Gastrointestinal mucormycosis

Twenty patients with gastrointestinal mucormycosis are reviewed. This often fatal opportunistic fungal infection was diagnosed histologically, and was categorized as colonization (five patients), infiltration (seven patients), or vascular invasion (eight patients). There were no fatalities from colonization. In 10 patients, mucormycosis complicated peptic ulcer disease. Seven of these patients had infiltrative or invasive disease. The presentation and operative findings mimicked malignancy in five of these seven patients, and six had successful surgical intervention. The other patient was cured by medical therapy alone. Ten patients had infection associated with other gastrointestinal diseases: post-traumatic peritonitis (four patients), transmural amoebiasis (two patients), tuberculosis (one patient), gastroenteritis (one patient), gastric carcinoma (one patient) and diabetes (one patient). Eight patients had significant infection and only one survived. In this series, mucormycosis had a less aggressive course when complicating peptic ulcer than when it occurred in association with other gut diseases.

Mucormycosis in an apparently normal host. Case study and literature review

Mucormycosis refers to an opportunistic fungal infection most often related to predisposing conditions, especially uncontrolled diabetes. It can occur as a rapidly extending rhinocerebral infection presenting a high mortality rate. The same micro-organism has, however, been identified in benign paranasal infections in the absence of a general debilitating condition, suggesting that host factors are of the utmost importance in the outcome of paranasal mucormycosis.

Mycotic infection and the pediatric surgeon

The incidence of major fungal infection in recent years has paralleled increasing use of immunosuppressive drugs, broad spectrum antibiotics and implantable catheters and prostheses. The pediatric surgeon encounters fungi as agents of perioperative infection and anatomic disease requiring surgical intervention. Clinical mycology is increasingly challenged by a wide spectrum of unfamiliar fungi, fungal infections and antimycotic drugs. An overview of the expanding role of surgical mycosis in children is presented.

Subcutaneous mucormycosis caused by Saksenaea vasiformis in a thalassaemic child: first case report in Thailand

A first case of subcutaneous infection caused by Saksenaea vasiformis in an 11-year-old Thai thalassaemic boy was described. The specific diagnosis of infection was attained from microscopic demonstration of the causal agent as well as the isolation of the fungus. The patient was successfully treated by debridement of the lesion and parenteral amphotericin B. The predisposing factors, source of infection and regimen for treatment are discussed.

Disseminated zygomycosis and systemic lupus erythematosus

A young woman with long-standing systemic lupus erythematosus and rheumatic fever presented with deteriorating renal function. She had severe gastritis treated with cimetidine and received methylprednisolone when her blood cultures were repeatedly negative. She developed spontaneous bruising and bleeding from venepuncture sites, leading to clotting studies and a diagnosis of thrombotic thrombocytopenic purpura. At post-mortem, extensive evidence of disseminated zygomycosis was found. The likely portal of entry was the gastric route.

Cutaneous mucormycosis

We report two cases of primary cutaneous mucormycosis in immunocompromised patients. Although their clinical presentation showed nonspecific necrotic ulcers, the histopathologic features were diagnostic. In both cases, broad, branching, nonseptate hyphae were found in the dermis and subcutaneous tissue. In one case the hyphae could be observed in the epidermis. To our knowledge, this is the only reported case of primary cutaneous mucormycosis with hyphae detectable in the epidermis.

A rapidly fatal palatal ulcer: rhinocerebral mucormycosis

A case of a patient with a palatal ulcer who was in a diabetic ketoacidotic coma is described. This ulcer proved to be the presenting sign of rhinocerebral mucormycosis. The patient had hemifacial swelling, ocular signs, and gross tissue destruction and died less than 4 weeks after she was first seen.

Host-parasite interaction in fungal infections

The outcome of host-parasite interactions in fungal infections is determined by the balance between pathogenicity of the organism and the adequacy of the host defenses. A wide variety of host defense mechanisms are involved in protection against fungal infections. These include nonspecific mechanisms such as intact skin and mucus membranes, indigenous microbial flora, and the fungicidal activity of neutrophils and monocytes. Such mechanisms constitute the major host defense against opportunistic fungal infections caused by ubiquitous organisms of low virulence. The effective role of immunoglobulins and complement as opsonins varies with the fungal pathogen involved. Specific immune responses of both the humoral and cell-mediated type develop in response to infections by pathogenic fungi. Antibodies, in general, are not of major importance in protection against these infections. Specifically sensitized T lymphocytes produce lymphokines that activate macrophages. Activated macrophages are the major line of defense against systemic fungal pathogens. The type and degree of impairment in immune responses determines the susceptibility and severity of diseases. The type of immune response also determines the tissue reactions in these diseases and sometimes may be involved in the pathogenesis of the disease process. The role of natural killer cell activity, antibody-dependent cellular cytotoxicity, and biological response modifiers in various fungal infections has been described recently. The microbial factors of importance in fungal infections are adherence, invasion, presence of an antiphagocytic capsule, and ability to grow under altered physiological states of the host. The differences in the virulence of fungal strains is of minor importance in determining the outcome in general. The seriousness of the alteration of the host state rather than the pathogenic properties of the fungus determine the severity of the disease.

Fatal fungal peritonitis in an adolescent on continuous ambulatory peritoneal dialysis: association with deferoxamine

An unusual case of Rhizopus microsporus (mucormycosis) fungal infection in a teenage boy on continuous ambulatory peritoneal dialysis is presented. Premortem cultures were negative and the patient developed a rapidly disseminated fatal infection. The patient was being treated with deferoxamine (DFO) for iron and aluminum overload. An argument is made for a probable association between DFO and this fatal fungal infection in patients with end-stage renal disease.

Orbital cellulitis due to mucormycosis. A case report

A case of orbital cellulitis caused by mucormycosis developed in a patient subsequent to cataract extraction and during systemic steroid treatment for postoperative complications. Fatal mucormycosis is a rare disease usually beginning with a subcutaneous inflammatory lesion. As the subsequent development of orbital cellulitis is very rare, little has been published on this subject. In cases of subcutaneous mucormycosis, the diagnosis can easily be made by means of histologic examination of the lesion. However, early diagnosis is difficult in cases with orbital involvement, because the most common cause of orbital cellulitis is bacterial. Thus, orbital cellulitis caused by mucormycosis is often wrongly treated with antibacterial agents only, as histologic examination is neither easy nor part of any routine investigation. Therefore, a combined treatment using antibiotics and antifungal agents in immunusuppressed patients with this disease is advocated.

Rhizopus arrhizus in Italy as the causative agent of primary cerebral zygomycosis in a drug addict

A rare case of primary cerebral zygomycosis in an Italian drug addict is described. The diagnosis was based on the histologic detection of broad, aseptate, hyaline mycelium in fluid aspirated from a brain mass detected by computerized axial tomography. The zygomycete isolated from the clinical specimen was identified as Rhizopus arrhizus var arrhizus. The patient had no known predisposing condition that would have suppressed his immunological defenses. Once the diagnosis was established, treatment with amphotericin B was initiated, but the patient died during the first day of treatment.

Orbital apex syndrome

A case is presented of a 16-year-old anticoagulated, immunocompromised male presenting with a blind, proptotic left eye, total ophthalmoplegia, and central retinal artery occlusion. Ophthalmic examination revealed other features of the orbital apex syndrome. Mucormycosis misdiagnosed as a traumatic orbital hemorrhage led to the patient's death. In this review, differential diagnosis of the orbital apex syndrome (loss of cranial nerves II, III, IV, ophthalmic division of V, and VI) is outlined, and features, diagnosis, and treatment of mucormycosis are discussed. Although mucormycosis is most commonly seen in diabetics, it should be considered in any immunocompromised patient presenting with the constellation of features of orbital apex syndrome.

Opportunistic zygomycotic infections. A literature review

This is a literature review of 361 opportunistic fungal infections caused by the Zygomycetes. The clinical and laboratory diagnosis, pathogenesis, management, treatment, and outcome of infection are discussed. The Zygomycetes are a group of opportunistic fungi (orders Mucorales and Entomophthorales) which cause severe infections which may be fatal. Early clinical recognition, prompt diagnostic procedures, control of underlying disease and treatment with high doses of amphotericin B and aggressive surgery increases survival in an otherwise lethal infection.

Bread mold infection in diabetes. The life-threatening condition of rhinocerebral zygomycosis

Rhinocerebral zygomycosis is a rare but dangerous fungal infection that affects primarily diabetic patients in ketoacidosis but other debilitated patients as well. A high index of suspicion among primary care physicians will lead to earlier diagnosis and help reduce the severe morbidity and mortality associated with the condition. Zygomycosis should be strongly suspected in diabetic patients presenting with unilateral headache, nasal congestion, or facial pain and swelling. If hyphae are not seen in nasal secretions on microscopy, biopsy of infected tissue must be done immediately to establish a diagnosis. Prompt treatment, including appropriate surgical intervention, amphotericin B therapy, and correction of metabolic derangements, is essential.

Infection in renal transplant recipients. Current approaches to diagnosis, therapy, and prevention

Despite dramatic improvements in patient and renal allograft survival, infections continue to be an important cause of post-transplantation morbidity and mortality. Most serious infections manifest clinically as febrile diseases, and immunosuppression-induced compromised cell-mediated immunity is the basis for the predominance of infections due to opportunistic intracellular microorganisms. Diagnostic evaluation is guided by the timing of fever after transplantation, epidemiologic factors, and evidence of specific organ system involvement. Although current therapy of bacterial and parasitic infections is usually effective, the management of deep-seated fungal infections remains highly unsatisfactory. Cytomegalovirus disease, the single most important infection in some transplant centers, frequently presents as a self-limited viral syndrome; however, multiple organs may be affected. New measures for the rapid diagnosis and treatment of this viral infection hold promise. A number of recommendations have been proposed to prevent infections in renal transplant recipients; however, continued progress will depend primarily upon further refinements in immunosuppressive therapy.

Clinical spectrum of pulmonary mucormycosis

Pulmonary mucormycosis is an uncommon, but important, opportunistic fungal pneumonia which is often diagnosed post-mortem. This review emphasizes clinical and pathologic characteristics of pulmonary mucormycosis that differentiate this infection from other fungal pneumonias. The most common clinical presentation of pulmonary mucormycosis is a rapidly progressive pneumonia with diffuse infiltrates on chest radiographic examination of a patient with an underlying hematologic malignancy treated with immunosuppressive drugs. Other immunocompromised hosts at risk for pulmonary mucormycosis include patients with diabetes mellitus who may develop a distinctive endobronchial form of this disease. Early consideration of this diagnosis, along with aggressive diagnostic evaluation, are critical to effective therapy and patient survival. While treatment with amphotericin B is the mainstay of therapy for pulmonary mucormycosis, diabetics with endobronchial disease may benefit from early, aggressive surgical resection of the involved lung tissue.

Invasive mucormycosis in a non-immunocompromised patient

Primary invasive cutaneous mucormycosis in a non-immunocompromised patient is described. Cultures from the infected tissues yielded a zygomycete which was identified as Saksenaea vasiformis. The patient was successfully treated with debridement of the lesion and amphotericin B.

Host-parasite relationship in opportunistic mycoses

Aspergillosis and mucormycosis are opportunistic fungal infections that share several unique features. The etiologic agents of aspergillosis and mucormycosis are ubiquitous in the environment, but are opportunistic organisms and usually infect only patients predisposed by some underlying disease or treatment. These infections are typically characterized by hyphal tissue invasion and a predilection of the organism for blood vessel invasion with hemorrhage, necrosis, and infarction. Also, these organisms are not dimorphic, like the true pathogenic dimorphic fungi, as they grow both in the environment and within the host in hyphal forms. However, the host must contend with several forms to successfully eliminate them. Each form displays different antigenic and surface features and elicits different host responses. Finally, if germination and hyphal growth occur, the host must compete with a rapidly growing organism that is too large to be ingested by a single cell and so must be handled by extracellular defense mechanisms.

Brain stem mucormycosis in a narcotic addict with eventual recovery

In addition to the well-known infectious complications of intravenous narcotic abuse, a much rarer and more recently recognized association between intravenous narcotic addiction and mucormycotic abscesses of the central nervous system has been described. Only four cases have been cited in the literature, with a mortality rate of 100 percent in this group. This report describes a narcotic abuser who presented with obstructive hydrocephalus and a mucormycotic abscess of the brain stem, and recovered. Central nervous system mucormycosis should be included in the differential diagnosis of drug abusers who present with a rapid deterioration in neurologic status.

Infectious complications of neoplastic disease

Progress has been made in the diagnosis and treatment of infection in patients with neoplastic disease. Among the advances is the appreciation that certain opportunistic infections occur in association with particular host immune defects and epidemiologic factors. Such immune defects are seen secondary to or as a consequence of treatment for the patient's basic disease. Improved methods such as serology, open lung biopsy, and fiberoptic bronchoscopy have allowed for earlier diagnosis and treatment of opportunistic infections. The development of empiric antibiotic regimens, particularly aminoglycosides and the antipseudomonal penicillins, have improved the outcome in the febrile neutropenic patient. The benefits of protective environments have been challenged; prophylactic antibiotics and various forms of immunotherapy are of interest but remain investigational.

Rhinocerebral mucormycosis: three case reports and subject review

Rhinocerebral mucormycosis (RCM) in the diabetic patient can be a particularly aggressive and devastating disease. The emergency physician will typically see patients with RCM in its earliest stages masquerading as a variety of other, less serious diseases. Early diagnosis is the key to a successful outcome. Three such cases seen in the emergency department are reviewed with attention to their initial clinical presentation and treatment. In addition, the historical, pathophysiologic, clinical, and therapeutic aspects of RCM are reviewed.