Unusual presentation of entomophthoromycosis

Entomophthoromycosis Presenting as a Nasal Mass

Entomophthoromycosis is a rare, invasive fungal infection common in tropics. Potential sources of infection could be contaminated soil, leaf litter, insects and water. High index of suspicion is needed as entomophthoromycosis mimics the common sinonasal disease in its nascent stage. Concurrent medical and surgical management is the most effective treatment.

Rhinofacial conidiobolomycosis: Clinical and microbiological characterisation and shift in the management of a rare disease

BACKGROUND

Conidiobolomycosis is a rare tropical rhinofacial fungal infection which has not been well characterised. The available evidence in its management is sparse due to lack of clinical studies and the limited data on antifungal susceptibility patterns.

OBJECTIVE

To analyse the clinical manifestations, antifungal treatment and outcomes of patients with conidiobolomycosis and to determine antifungal susceptibility profiles of the isolates.

PATIENTS/METHODS

Retrospective analysis of data of all patients with a diagnosis of conidiobolomycosis confirmed by histopathology and culture at a tertiary care hospital from 2012 to 2019 was done.

RESULTS

There were 22 patients, 21 males and one female, with a mean age of 37.1 years. Most common presenting symptom was nasal obstruction, found in 20 (90.90%) patients. Patients who presented within 12 months had a better cure rate (85%) compared to those who presented late (67%). Among the 19 patients who had a follow-up, good outcome was seen in 15 of the 17 (88.24%) patients who were on itraconazole or potassium iodide containing regimen. Of the six patients who received additional trimethoprim-sulphamethoxazole (co-trimoxazole), 67% showed good outcome with two patients showing complete cure and two patients still on treatment with significant improvement. High minimum inhibitory concentration (MIC) values were noted for azoles and amphotericin B, whereas co-trimoxazole showed lowest MIC ranges.

CONCLUSION

Itraconazole and potassium iodide are reasonable first-line options for the treatment of conidiobolomycosis. Good clinical response to KI and comparatively lower MIC of co-trimoxazole are promising. Further studies are required for developing clinical breakpoints that can predict therapeutic outcomes.

Entomophthoramycosis: A diagnostically challenging presentation of liver space-occupying lesion

Entomophthoramycosis, a rare fungal infection, can mimic various clinical entities. We present a case of entomophthoramycosis affecting a 3-year-old male masquerading as liver tumour, diagnosed on stereotactic biopsy and later on resected specimen. He improved following partial hepatectomy and antifungal therapy. A high index of suspicion and heightened awareness regarding its unique morphological characteristics are required for appropriate management.

Conidiobolus, a hitherto unidentified pathogen in microbial keratitis

Fungal infections are a significantly increasing cause of ocular and systemic morbidity; the vast majority of cases being ascribed to a handful of species. Fungal keratitis, unlike systemic infections, usually occur in immunocompetent individuals. Rarely, systemic infections can be associated with ocular involvement (e.g., Candida, Mucor, Pythium), or a fungus that predominantly causes systemic disease can affect the eye. One such fungus is Conidiobolus which is known to cause muco-cutaneous infections. We report the identification and successful treatment of a case of Conidiobolus corneal ulcer in an immunocompetent individual, who had no co-existing muco-cutaneous disease. Identification of this particular fungus and awareness of its potential to cause systemic disease is especially relevant, given its potential for chronic indolent infection of the subcutaneous tissues. To the best of our knowledge, this is the first reported case of a Conidiobolus corneal ulcer.

Human Pathogenic Entomophthorales

The pathogenic entomophthoralean fungi cause infection in insects and mammalian hosts. Basidiobolus and Conidiobolus species can be found in soil and insect, reptile, and amphibian droppings in tropical and subtropical areas. The life cycles of these fungi occur in these environments where infecting sticky conidia are developed. The infection is acquired by insect bite or contact with contaminated environments through open skin. Conidiobolus coronatus typically causes chronic rhinofacial disease in immunocompetent hosts, whereas some Conidiobolus species can be found in immunocompromised patients. Basidiobolus ranarum infection is restricted to subcutaneous tissues but may be involved in intestinal and disseminated infections. Its early diagnosis remains challenging due to clinical similarities to other intestinal diseases. Infected tissues characteristically display eosinophilic granulomas with the Splendore-Höeppli phenomenon. However, in immunocompromised patients, the above-mentioned inflammatory reaction is absent. Laboratory diagnosis includes wet mount, culture serological assays, and molecular methodologies. The management of entomophthoralean fungi relies on traditional antifungal therapies, such as potassium iodide (KI), amphotericin B, itraconazole, and ketoconazole, and surgery. These species are intrinsically resistant to some antifungals, prompting physicians to experiment with combinations of therapies. Research is needed to investigate the immunology of entomophthoralean fungi in infected hosts. The absence of an animal model and lack of funding severely limit research on these fungi.

Rhinofacialentomophthoromycosis

Entomopthoromycosis is a rare subcutaneous fungal infection caused by onidiobolus coronatus affecting mainly the upper respiratory mucosa in immunocompetent people.The manifestations of this disease masquerades other clinical entities.Hence, high index of suspicion is required for prompt diagnosis.Histopathological examination and culture are the gold standard diagnostic tools, however no standard treatment protocols ha been mentioned in literature.We present a case of rhinofacial entomopthoromycosis in a yearold ma with a leftsided rhinofacial swelling to highlight the presence of this unusual fungal infection and its treatment.

Concurrent Infections of Conidiobolus Coronatus with Disseminated Tuberculosis Presenting as Bilateral Orbital Cellulitis

Zygomycetes species contains two orders of organisms that infect humans, namely Mucorales and Entomophthorales. Entomophthorales cause chronic infection in immunocompetent patients, invading subcutaneous tissues but are non-angioinvasive. This includes Basidiobolus ranarum, Conidiobolus incongruus and Conidiobolus coronatus. We report a case of disseminated tuberculosis with Conidiobolus coronatus infection presenting as orbital cellulitis in an adolescent.

Orofacial infection by Conidiobolus coronatus

Entomophtoramycosis is a type of subcutaneous mycosis which includes both basidiobolomycosis and conidiobolomycosis; the latter is caused by Conidiobolus coronatus, a saprophytic fungus which lives in tropical soils. This mycosis characteristically affects the paranasal sinuses and oropharynx, with the potential to deform the face in patients without apparent immunodeficiency. It has a chronic course of infection with a tendency to form granulomas visible using histology. We present the case of a 28 year-old male agricultural worker, with a clinical profile of 6 months' evolution of rhinofacial tumefaction, nasal obstruction and post-nasal drip who was diagnosed with conidiobolomycosis by means of tissue culture after multiple biopsies of the facial area. The patient received antifungal treatment with amphotericin B and subsequently with itraconazol, resulting in a dramatic improvement without the need for surgical treatment; itraconazol was administered for one year and there was no evidence of relapse at the end of this period. Due to the low frequency of this disease there is no established treatment strategy; however, the use of azoles such as itraconazol with or without adjuvant surgical treatment is increasingly seen in case reports. The present report adds to the clinical experience in Colombia of this rare mycosis and also describes the long-term clinical and therapeutic response.

Subcutaneous mycoses in coastal Karnataka in south India

BACKGROUND

Subcutaneous mycoses are chronic, localized infections of the skin and subcutaneous tissue which occur following traumatic implantation of the etiological agent. The causative organisms are soil saprophytes of regional epidemiology with varying ability to adapt to the tissue environment and elicit disease.

OBJECTIVES

This study was conducted to evaluate the various types of subcutaneous mycoses, including actinomycotic mycetomas, in south coastal Karnataka, India.

METHODS

Between January 2005 and January 2013, a total of 25 patients were diagnosed with subcutaneous mycoses based on a detailed clinical history and presentation, histopathology, and culture of organisms.

RESULTS

Chromoblastomycosis was the infection most commonly seen (n = 16 patients, 64%), followed by mycetoma (n = 4, 16%), sporotrichosis (n = 4, 16%), and rhinoentomophthoromycosis (n = 1, 4%). The extremities were the most common site of involvement, with the lower limb being most affected (64%). Males were more commonly afflicted (64%) than females (36%). Most patients were agricultural workers, although preceding trauma was noted in only three patients. The majority of patients responded well to therapy and were disease-free on follow-up.

CONCLUSIONS

Subcutaneous mycoses are a rare group of disorders. Chromoblastomycosis is the most frequent subcutaneous fungal infection in south India. Morphologically, chromomoblastomycoses present as verrucous, ulcerative, nodular, or eczematous lesions. Clinical diagnosis is important as culture is often negative. The incidence of infection is higher among rubber tappers. It is important to clinically differentiate chromoblastomycosis from tuberculosis verrucosa cutis. Most of the subcutaneous mycoses respond well to treatment, with the exception of rhinoentomophthoromycosis, which is a rare form of deep mycosis with associated mutilation. Eumycetomas are not observed in this part of India.

Entomophthoromycosis: a challenging emerging disease

Entomophthoromycosis is a rare fungal infection that may affect immunocompetent hosts; predominantly in tropical and subtropical regions. Recently, the importance of this emerging mycosis has increased and the scope of its manifestations has been expanded. These manifestations; however, may masquerade as other clinical entities. Prompt diagnosis of this infection requires a high index of suspicion. Although histopathological examination and cultures are the gold standard diagnostic tools; molecular diagnosis is now available and started to play an important role. The cornerstone treatment is prolonged anti-fungal therapy along with surgical debridement. More awareness of this mycosis is warranted for definitive diagnosis and implementation of early proper therapeutic strategies.

Rhino facial zygomycosis: case report

Zygomycosis is an invasive disease that affects both immunocompetent and immunocompromised, depending on the type of strain. This disease diagnosis is clinical and histopathological, and its treatment is based on antifungal therapy and surgical cleaning. This paper reports a case of a boy with invasive zygomycosis rinofacial who final treatment was successful after underwent antifungal and surgical therapies.

Rhinoentomophthoromycosis due to Conidiobolus coronatus. A case report and an overview of the disease in India

Rhinoentomophthoromycosis due to Conidiobolus coronatus is a rare, chronic, granulomatous disease, occurring mainly in tropical Africa, South and Central America and south-east Asia, including India. We report a case of rhinoentomophthoromycosis in a 30-year-old male farmer, a resident of Gorakhpur city in Uttar Pradesh, which was diagnosed by histopathology and isolation C. coronatus in culture. The patient presented with a swollen nose with obstruction that had progressed slowly over one year. His nasal swelling was bilateral, diffuse, mildly tender, erythematous, non-pitting, with mucosal crusting and hypertrophy of inferior turbinates but no regional lympha-denopathy. A contrast-enhanced computed tomography (CECT) scan revealed bilateral pan-sinusitis with nasoethmoid polyposis. Culture of tissue from the nasal biopsy on Sabouraud glucose agar yielded multiple colonies of a mold with satellite smaller colonies at periphery. The isolate demonstrated the macroscopic and microscopic morphologic characteristics of C. coronatus. Its identity was further confirmed by direct DNA sequencing of internal transcribed spacer (ITS) and D1/D2 regions of rDNA. Haemotoxylin and eosin stained tissue sections of the skin biopsy revealed irregular epidermal acanthosis, marked inflammatory and granulomatous reaction with sparse, non-septate hyphae. The patient was treated successfully with a combination therapy of oral saturated potassium iodide solution, itraconazole, and intravenous infusion of amphotericin B. An overview of rhinoentomophthoromycosis cases reported to-date in India is presented.

Molecular Characterization of Ovine Zygomycosis in Central Western Brazil

Zygomycosis is an important granulomatous disease that affects humans and animals, particularly sheep in tropical regions. Rhinofacial and nasopharyngeal zygomycosis were described in sheep in association with Conidiobolus spp. The present study characterized 5 samples of Conidiobolus isolated from 3 herds with clinical disease in Mato Grosso State, Brazil. The clinical and pathological findings were similar to nasopharyngeal zygomycosis. Based on morphological features, isolates were classified as Conidiobolus spp., and molecular phylogenetic analyses based on 18S ribosomal DNA grouped all isolates in a Conidiobolus lamprauges cluster. The current report describes the molecular characterization of ovine nasopharyngeal zygomycosis associated with C. lamprauges.