Conidiobolomycosis in Sheep in Brazil

Conidiobolomycosis is reported in the state of Piauí, in the semiarid region of northeastern Brazil. Affected sheep had depression, weight loss, serous or mucohemorrhagic nasal discharge, and cranium-facial asymmetry from exophthalmos of 1 eye, generally with increased volume of the eyeball, keratitis, and corneal ulceration. At necropsy of 60 sheep, friable masses were observed in the posterior region of the nasal cavity, often destroying the ethmoturbinate bones. Frequently, the lesions invaded the nasal sinuses, cribiform plate, orbit, and brain. The masses were irregular, granular with moist surfaces, and soft and friable with white, yellow, or tan coloration. Dissemination of the lesion to lungs was observed in 27 sheep, to the brain in 26, to lymph nodes in 3, to the kidney in 2, and to the gallbladder and heart in 1. The microscopic examination showed granulomatous inflammation composed of central necrosis surrounded by lymphocytes, epithelioid and giant cells, and fibrous tissue. In all lesions, negatively stained structures representing hyphae were surrounded by Splendore-Hoeppli material. Coagulative necrosis, thrombosis, and vasculitis were also observed. Grocott methenamine silver stain showed 8–30-μm-thick hyphae, rarely septate or ramified, irregular in shape, and with black contoured wall, sometimes with bulbous dilatation in the extremities. On electron microscopy, the hyphae had a thick double wall surrounded by cellular remnants and an inflammatory exudate. Conidiobolus coronatus was isolated from the lesions of 6 sheep. Conidiobolomycosis is an important disease of sheep in the state of Piauí, and other regions of northeastern Brazil.

Emergence of gastrointestinal basidiobolomycosis in the United States, with a review of worldwide cases

BACKGROUND

We examined the epidemiology, clinical manifestations, histopathology, management, and outcomes of gastrointestinal basidiobolomycosis, an uncommon manifestation of infection caused by the fungus Basidiobolus ranarum.

METHODS

In this retrospective observational cohort study, cases of gastrointestinal basidiobolomycosis in the United States were identified by reviewing medical records from Mayo Clinic Hospital (Phoenix, AZ) and contacting local infectious diseases specialists, pathologists, gastroenterologists, the Arizona Department of Health Services, health departments of adjacent states, the Armed Forces Institute of Pathology, and the US Centers for Disease Control and Prevention. A comprehensive literature review identified additional cases worldwide.

RESULTS

Of 44 patients (mean age, 37 years [range, 2-81 years]) with gastrointestinal basidiobolomycosis, most were from the United States (19 patients [43%], of whom 17 [89%] were from Arizona) or Saudi Arabia (11 [25%]). Most (28 [64%]) were previously healthy. Common chronic medical conditions among 15 patients (34%) were diabetes mellitus (8 patients [18%]) and gastric disorders (7 [16%]). Common findings were abdominal pain (37 patients [84%]) and a palpable abdominal mass (19 [43%]). Intraabdominal malignancy was the leading provisional diagnosis (19 patients [43%]). The large bowel was involved in 36 (82%), the small intestine in 16 (36%), and the liver or gallbladder in 13 (30%). Characteristic histopathologic findings were observed in 43 (98%). Eight patients (18%) died. Combined surgical intervention and antifungal therapy was the preferred treatment.

CONCLUSIONS

Gastrointestinal basidiobolomycosis is an emerging invasive fungal infection in desert regions of the US Southwest. Clinical findings mimic malignancy and inflammatory bowel disease. Surgical excision and prolonged antifungal therapy are associated with favorable outcomes.

Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome

OBJECTIVE

To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period.

METHODS

Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck.

RESULTS

Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001).

CONCLUSIONS

In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Primary cutaneous zygomycosis from a tertiary care centre in north-west India

BACKGROUND & OBJECTIVES

Zygomycosis is highly invasive fungal infection, with high mortality rate. In most of patients, diabetes mellitus is an underlying factor but in primary cutaneous zygomycosis, presentation may be different. Here we present the description of clinical presentation, fungi isolated and management of cases with cutaneous zygomycosis seen in a tertiary care hospital in north India during 2001-2007.

METHODS

All patients diagnosed with primary cutaneous zygomycosis between November 2001 and September 2007 presenting with clinical diagnosis of necrotizing fasciitis were included. Detailed history of each patient was taken, clinical presentation, site of involvement, underlying illness and risk factor, if any were noted. The diagnosis was established by direct microscopic evidence of broad, aseptate or sparsely septate ribbon-like hyphae with right angle branching in KOH wet mount and histopathological examination of stained sections. Cultures were put up for fungal isolation and species identification. Outcome of the therapy was analysed.

RESULTS

Of the nine patients reviewed, only one had diabetes mellitus. Commonest risk factor was injection abscess (33.3%). Apophysomyces elegans was isolated in four cases, Saksenaea vasiformis and Absidia corymbifera in one each. The fungal culture was sterile in three cases. Mortality rate was high with only four patients responded well to surgical and/or medical therapy.

INTERPRETATION & CONCLUSION

Primary cutaneous zygomycosis appears to be on rise in India that calls for high index of clinical suspicion and an early biopsy of the affected area for timely diagnosis. The standard treatment is a combination of amphotericin B therapy, surgical debridement, and reversal of the underlying disease or immunosuppression.

[Zygomycetes and zygomycosis in the new era of antifungal therapies]

Zygomycosis or mucormycosis is the third most invasive fungal infection after candidiasis and aspergillosis. Traditionally, it has been considered a community-acquired disease, but it is becoming a frequent nosocomial-acquired disease. Recently, several publications from different institutions have reported an increase in the number of cases of invasive zygomycosis as a result of the new antifungal and immunosuppresive therapies and the emerging immunocompromised population. In addition, the diagnosis of zygomycosis is elusive, mainly in pulmonary and disseminated forms. One of the main limitations in isolating Zygomycetes from clinical samples is the interpretation of results. The increasing number of invasive fungal infections caused by multiresistant fungi has led to the development of new antifungal drugs with variable activity against Zygomycetes.

[Spectrum and risk factors of invasive fungal infection]

In recent years, invasive fungal infection has become a growing problem in immunosuppressed patients. Simultaneously, changes in medical practice, such as the use of anti-Candida prophylaxis with azoles, has led to a shift in the epidemiology of these infections from Candida spp. to Aspergillus and other filamentous molds. Moreover, new risk factors for invasive fungal infection have been identified and the time of onset is different from that seen a decade ago. Recognition of these trends in patients receiving novel immunosuppressive regimens has important implications for the clinical management of fungal infection in this population.

[Invasive zygomycosis: notably in diabetes mellitus and iron overload]

The incidence of invasive zygomycosis, a severe and often life-threatening infection, is increasing. The most common manifestations are pulmonary infection (following anti-cancer chemotherapy or haematopoietic stem-cell transplant) and invasive rhinocerebral infection (in patients with diabetes mellitus or iron overload). Iron metabolism plays an important role in the pathogenesis of infection in these high-risk populations. Rapid diagnosis, reversal of the underlying predisposition and timely surgical debridement are the underlying principles of therapy for this disease.

[Invasive zygomycosis in patients treated for haematological malignancies]

A 52-year-old man underwent haematopoietic stem-cell transplant for myelodysplastic syndrome; after treatment with voriconazole for invasive aspergillosis, he was diagnosed with invasive zygomycosis caused by Rhizopus microsporus. He died despite treatment with intravenous liposomal amphotericin B and posaconazole. A 5-year-old boy with acute lymphatic leukaemia was diagnosed with invasive zygomycosis at autopsy. In a third case, a 16-year-old boy with acute myeloid leukaemia received repeated courses of empiric antifungal therapy, although the presence of an invasive fungal infection was not demonstrated. The patient died, and disseminated invasive zygomycosis caused by Rhizomucor pusillus was found at autopsy. Invasive infections by Zygomycetes are difficult to diagnose and are associated with a high mortality rate. The incidence of invasive zygomycosis appears to be increasing. Therefore, awareness of this type of invasive fungal infection is warranted. Lipid formulations ofamphotericin B remain the first choice for therapy.

Indicaciones actuales de voriconazol en pacientes onco-hematológicos

Invasive fungal infections (IFI) are the main cause of infectious death in cancer patients, especially in hematological malignancies and hematopoietic transplant recipients. Current epidemiology is characterized by a predominance of IFI caused by molds, mainly aspergillosis, along with a emergence of hard-to-treat fungi such are Zygomicetes, Fusarium and Scedosporium. Voriconazole is a broad spectrum antifungal agent with oral and intravenous formulations, approved by the EMEA for the treatment of invasive aspergillosis, candidemia in non-neutropenic patients, IFI caused by fluconazole-resistant species of Candida as well as Scedosporium and Fusarium infections. However, its use in clinical practice is broader, as empirical antifungal treatment and as secondary prophylaxis. It should be kept in mind the possibility of breakthrough IFI, particularly zygomycosis, in patients treated with voriconazole for long periods.

Estado actual del diagnóstico precoz de las infecciones invasoras causadas por Aspergillus y otros hongos filamentosos emergentes

The usefulness of surrogate markers in the diagnosis of invasive fungal infections caused by Aspergillus and other emerging mycelial fungi is based on the ability of surrogate markers to detect the infection caused by different species of mycelial fungi. Conventional microbiological methods for diagnosis of fungal disease are slow and insensitive. Antigen based assays or measurement of (1-3)-beta-D-glucan in blood have been developed and validated in clinical laboratories. We review these diagnostic contemporary tools, their clinical application and impact.

Zygomycosis in children: a systematic review and analysis of reported cases

BACKGROUND

Zygomycosis has emerged as an increasingly important infection with a high mortality especially in immunocompromised patients. No comprehensive analysis of pediatric zygomycosis cases has been published to date.

METHODS

We used a PUBMED search for English publications of pediatric (0-18 years) zygomycosis cases and references from major books as well as single case reports or case series. Individual references were reviewed for additional cases. Data were entered into Filemaker-pro database and analyzed by logistic regression analysis.

RESULTS

One hundred fifty-seven cases (64% male) were found with median age 5 years (range, 0.16-13). Underlying conditions included neutropenia (18%), prematurity (17%), diabetes mellitus (15%), ketoacidosis (10%), and no apparent underlying condition (14%). The most common patterns of zygomycosis were cutaneous (27%), gastrointestinal (21%), rhinocerebral (18%), and pulmonary (16%). Among 77 culture-confirmed cases, Rhizopus spp. (44%) and Mucor spp. (15%) were most commonly identified. Of 81 patients who were given antifungal therapy, 73% received an amphotericin B formulation only. The remaining patients received mostly amphotericin B in combination with other antifungal agents. Mortality in patients without antifungal therapy was higher than in those with therapy (88% versus 36%, P < 0.0001). Ninety-two (59%) patients underwent surgery. Cerebral, gastrointestinal, disseminated and cutaneous zygomycosis were associated with mortality rates of 100, 100, 88, and 0%, respectively. Independent risk factors for death were disseminated infection (OR: 7.18; 95% CI: 3.02-36.59) and age <1 year (OR: 3.85; 95% CI: 1.05-7.43). Antifungal therapy and particularly surgery reduced risk of death by 92% (OR: 0.07; 95% CI: 0.04-0.25) and 84% (OR: 0.16; 95% CI: 0.09-0.61), respectively.

CONCLUSIONS

Zygomycosis is a life-threatening infection in children with neutropenia, diabetes mellitus, and prematurity as common predisposing factors, and there is high mortality in untreated disease, disseminated infection, and age <1 year. Amphotericin B and surgery significantly improve outcome.

Zygomycosis ? current epidemiological aspects

Zygomycoses are very rare invasive fungal infections (IFI). They primarily occur in the immunocompromised patients and are associated with a high mortality. During the last years, a rising incidence of zygomycosis in patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) has been reported, which is probably a part of the trend in the incidence of mould infections that has been going on for decades. Difficulty in diagnosis, especially concerning the differentiation of zygomycosis from the far more common aspergillosis, additionally hampers a reliable assessment of the incidence of zygomycosis. In patients undergoing allogeneic HSCT, changes in the frequency, severity and management of Graft-versus-Host-Disease (GvHD) also favour mould infections, among them zygomycosis. In centres employing voriconazole for prophylaxis of IFI since its approval for treatment in 2001, incidence of aspergillosis has markedly dropped. The assumption that the frequency of zygomycosis has increased since the introduction of voriconazole is not found in prospective trials and therefore needs verification, especially when considering the long ongoing trends in fungal incidence. Currently recruiting multicentre trials on primary prophylaxis of IFI will have to show the preventive effectiveness of antifungals with mould activity and the incidence of zygomycosis under prospectively controlled conditions.

Impact of zygomycosis on microbiology workload: a survey study in Spain

This multicenter, population-based study evaluated the laboratory workload produced by zygomycetes and the number of cases of zygomycosis in Spain during 2005. Less than 8% of the patients who harbored zygomycete isolates had zygomycosis. The incidence of zygomycosis (6 cases) was 0.43 cases/1,000,000 inhabitants and 0.62 cases/100,000 hospital admissions.

Decrease in the number of reported cases of zygomycosis among patients with diabetes mellitus: a hypothesis

The number of reported cases of zygomycosis in patients with diabetes mellitus in developed countries has decreased since the 1990s, despite the rapid increase in the prevalence of diabetic patients in the Western world. Although prospective population-based studies need to better document this phenomenon, which may have a complex explanation, here I propose the hypothesis that widespread use of statins in patients with diabetes underlies such a trend. Statins have been shown to direct inhibitory activity against a range of Zygomycetes molds, both in vitro and in vivo.

Breakthrough zygomycosis after voriconazole administration among patients with hematologic malignancies who receive hematopoietic stem-cell transplants or intensive chemotherapy

Zygomycosis is increasingly reported as a cause of life-threatening fungal infections. A higher proportion of cases reported over the last decades have been in cancer patients, with or without hematopoietic stem cell transplantation (HSCT). The new anti-fungal agent voriconazole is a recently identified risk factor for developing zygomycosis. We reviewed the clinical characteristics and outcomes of a large cohort of cancer patients who developed zygomycosis after exposure to voriconazole. Health care professionals at 13 large cancer centers provided clinical information on cancer patients with zygomycosis and prior exposure to voriconazole. Criteria for inclusion were 5 days or more of voriconazole use and diagnostic confirmation with tissue or histology. Fifty-eight cases were identified among patients with hematologic malignancies, 62% including patients who underwent a HSCT procedure. Fifty-six patients received voriconazole for primary or secondary prophylaxis against fungal infection. In addition to prior exposure to voriconazole, patients also had several of the previously established risk factors for zygomycosis. Amphotericin B was the most commonly prescribed anti-fungal therapy. Overall mortality was 73%. We conclude that zygomycosis after exposure to voriconazole is a recently described entity that is frequently fatal, despite treatment with currently available anti-fungal agents and surgery.

Multidrug-resistant endosymbiotic bacteria account for the emergence of zygomycosis: A hypothesis

Although the extensive use of Aspergillus-active antifungals has been recently associated with an increase in zygomycosis in several cancer centers, the frequency of this opportunistic mycosis began to rise earlier, since the mid 1990s. The reasons for that emergence are unclear. Recent evidence suggests that endosymbiotic bacteria of Rhizopus species produce toxins that enhance fungal pathogenicity. We postulate that, although Zygomycetes appear equally ubiquitous and virulent to Aspergillus, zygomycosis was rare in the past in immunosuppressed patients specifically because of the widespread use of antibacterials in this patient population. Such use may have resulted in inhibition of endosymbiotic, toxin-producing bacteria and led indirectly in attenuation of Zygomycetes virulence. Thus, the growing rates of antimicrobial resistance over the past decade selected for multidrug-resistant endosymbiotic bacteria of Zygomycetes, which could facilitate the emergence of zygomycosis. This hypothesis, if true, will be the first paradigm of modulation of virulence of opportunistic fungi by antibacterials.

Changing Epidemiology of Rare Mould Infections

There has been an increase in rare mould infections in recent decades. These infections have been reported primarily in severely immunocompromised patients. The emergence of these organisms is multifactorial and can be related to more intense immunosuppression, the prolonged survival of patients who have what were previously fatal diseases, and the selective pressure of broad spectrum antifungal agents used for prophylaxis or therapy. Among these rare mould infections, the Zygomycetes are the most commonly encountered, and in some institutions the increase in these organisms appears to be associated with the use of voriconazole. Aspergillus terreus, a species that is resistant to amphotericin B, and less frequently, A. ustus and A. lentulus, have been noted increasingly as causes of invasive aspergillosis in tertiary care centres in the US. Several species of Scedosporium with innate resistance to many antifungal agents have emerged as major causes of disseminated mould infections that are frequently very difficult to treat. Among patients who have haematological malignancies, are neutropenic or have received a haematopoietic stem cell transplant, infections due to Fusarium species respond poorly to many antifungal agents. Dematiaceous, or brown-black, fungi, most often associated with chronic localised infections, are now increasingly reported as a cause of disseminated infection in immunosuppressed hosts. Concomitant with the increased number of infections with these rare moulds, several new mould-active antifungal agents have been developed. The new expanded spectrum azole, voriconazole, has changed our approach to moulds such as S.apiospermum, Fusarium species and A. terreus that are amphotericin B resistant. Posaconazole, the most recently approved expanded spectrum azole, is the first drug in the azole class to show activity against the Zygomycetes and has proven extremely useful for step-down therapy after initial treatment with amphotericin B. It is not known whether posaconazole is effective as primary therapy for zygomycosis; the use of this agent for that purpose awaits clinical trials with the recently developed intravenous formulation of posaconazole.

Zygomycosis in solid organ transplant recipients in a tertiary transplant center and review of the literature

Zygomycetes are ubiquitous fungi that can cause invasive disease associated with high mortality. We report 10 solid organ transplant recipients with zygomycosis (incidence 2 per 1000) and reviewed 106 cases in the English-language literature. These included renal (n = 73), heart (n = 16), lung (n = 4), heart/lung (n = 2), liver (n = 19) and kidney/pancreas (n = 2) transplant recipients. All patients were receiving immunosuppression and the vast majority steroids. The clinical presentation included rhino-sino-orbital (n = 20), rhinocerebral (n = 16), pulmonary (n = 28), gastrointestinal (n = 13), cutaneous (n = 18), renal (n = 6) and disseminated disease (n = 15). Most frequently isolated genera were Rhizopus (73%) followed by Mucor (13%). The overall mortality was 49%. While rhino-sino-orbital disease had the best prognosis, rhinocerebral disease had high mortality (93%) comparable to disseminated disease. A favorable outcome was associated with limited, surgically accessible disease and early surgical intervention along with amphotericin B administration.

[Zygomycosis after hematogeneic stem cell transplantation--a current problem?]

Zygomycoses are rare but often lethal mold infections predominantly affecting immunocompromised patients. Over the last years, several tertiary-care cancer centers reported an increase in the incidence of zygomycete infections in allogeneic blood stem cell transplant recipients. These observations are based on a small number of patients and should be considered in the context of a decades-long increase of mold infection rates. Diagnostic obstacles, including the difficult discrimination from the tenfold more frequent aspergilloses, may confound the reported incidences of zygomycete infections. These may be due to changes in frequency, severity and management of graft-versus-host disease promoting filamentous fungal infections, including zygomycoses. Hospitals applying long-term voriconazole prophylaxis in high-risk patients report a significant decrease in aspergillosis rates since the drug became available in 2001. The observation of increased frequencies of zygomycete infections during this period of time is not based on prospective evaluations. Therefore, the causes of these findings remain a matter of debate. Current multicenter trials on antifungal prophylaxis in high-risk patients promise to generate reliable data on the protective effect of antifungals active against molds, and the incidence of zygomycete infections in a controlled setting.

The changing epidemiology of invasive fungal infections: new threats

The epidemiology of invasive fungal infections is currently at a crucial stage. Potentially fatal fungal strains are emerging that are resistant to many commonly used antifungal agents. It is therefore important to recognize and minimize the major risk factors associated with infection. This paper summarizes the key epidemiological data.

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.

Outbreak of disseminated zygomycosis and concomitant pulmonary aspergillosis in breeder layer cockerels

Disseminated zygomycosis and concomitant pulmonary aspergillosis were diagnosed in breeder layer cockerels. Five- to 9-week-old breeder layer cockerels with a history of an increased mortality rate were presented to a diagnostic laboratory for examination. On necropsy, large, multifocal, firm, tan, nodules were observed in the lungs, air sacs, peritoneum, livers, spleens and kidneys. On histopathology, mixed populations of zygomycetes and Aspergillus hyphae were observed in the granulomas in the lungs, and zygomycete hyphae were observed in the granulomas in the air sacs, peritoneum, livers, spleens and kidneys. No bacteria were isolated from any of the lesions. Aspergillus fumigatus was isolated from the lung lesions only and hyphae that were consistent with those of a Rhizopus spp. were isolated from the lesions in several organs. Pullets, which were kept together with the cockerels from the day they were hatched, were not affected. The absence of infection in the pullets, which were kept together with the cockerels, suggests that the cockerels were either infected during incubation, with the fungi penetrating the egg shell, or that they were infected during hatching before they were mixed with the pullets.

The rising trend of invasive zygomycosis in patients with uncontrolled diabetes mellitus

Zygomycosis is an emerging infection worldwide. A study was conducted to understand its spectrum in the Indian scenario. All patients diagnosed for invasive zygomycosis at a tertiary care center in north India from 2000-2004, were retrospectively analyzed. A total of 178 cases (mean average of 35.6 cases/year) of zygomycosis were diagnosed. Rhino-orbito-cerebral type (54.5%) was the commonest presentation followed by cutaneous (14.6%), disseminated (9.0%), and gastrointestinal (8.4%) zygomycosis. Renal and pulmonary zygomycosis were seen in 6.7% patients each. Uncontrolled diabetes mellitus (in 73.6% of cases) was the significant risk factor in all types (Odds Ratio 1.5-8.0) except renal zygomycosis. Breach of skin was the risk factor in 46.2% patients with cutaneous zygomycosis. However, no risk factor could be detected in 11.8% patients. Antemortem diagnosis was possible in 83.7% cases. The commonest (61.5%) isolate was Rhizopus oryzae followed by Apophysomyces elegans in 27% patients. Combination of debridement surgery and amphotericin B therapy was significantly better in survival of the patients (P<0.005) than amphotericin B alone (79.6% vs. 51.7% survival). Thus, a rising trend of invasive zygomycosis was observed in patients with uncontrolled diabetes mellitus in India. Consistent diagnosis of renal zygomycosis in apparently healthy hosts and the emergence of A. elegans in India demand further study.

Zygomycosis: An emerging fungal infection

PURPOSE

The epidemiology, pathogenesis, clinical presentation and diagnosis, and management of zygomycosis are reviewed.

SUMMARY

The frequency of zygomycosis has been increasing over the past 10 years; infections have been identified in up to 6.8% of patients at autopsy. The most common route of transmission for Zygomycetes fungi is inhalation of spores from the environment. Patients at highest risk for infections caused by Mucorales fungi include those with profound immunosuppression or diabetes, intravenous drug abusers, premature infants, those receiving deferoxamine, and recipients of bone marrow transplants. Mucormycosis commonly presents as rhinocerebral or pulmonary disease; gastrointestinal presentations also occur. Clinical manifestations of invasive mucormycosis are tissue necrosis and subsequent thrombosis. Common features of pulmonary disease include fever, dyspnea, hemoptysis, and cavitation upon radiologic examination. The mainstays of treatment are control or reversal of the underlying disease or immunosuppression, antifungal therapy, and aggressive surgical debridement. Posaconazole, a new triazole antifungal, has been used successfully in a number of cases that did not respond to amphotericin B.

CONCLUSION

Zygomycosis appears to be on the rise in the United States. The standard treatment is a combination of amphotericin B therapy, surgical debridement, and reversal of the underlying disease or immunosuppression.

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.

Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer

BACKGROUND

Pulmonary zygomycosis (PZ), an emerging mycosis among patients with cancer, has a clinical manifestation similar to that of invasive pulmonary aspergillosis (IPA). Most cases of PZ in such patients develop as breakthrough infections if treatment with antifungal agents effective against Aspergillus species is administered. However, clinical criteria to differentiate PZ from IPA are lacking.

METHODS

We retrospectively reviewed the clinical characteristics and computed tomography (CT) findings for 16 patients with cancer and PZ and for 29 contemporaneous patients with cancer and IPA at the time of infection onset (2002-2004). Patients with mixed infections were excluded. Parameters predictive of PZ by univariate analysis were included in a logistic regression model.

RESULTS

Almost all patients with PZ (15 of 16) and IPA (28 of 29) had underlying hematological malignancies and typical risk factors for invasive mold infections. In logistic regression analysis of clinical characteristics, concomitant sinusitis (odds ratio [OR], 25.7; 95% confidence interval [CI], 1.47-448.15; P = .026) and voriconazole prophylaxis (OR, 7.76; 95% CI, 1.32-45.53; P = .023) were significantly associated with PZ. The presence of multiple (> or = 10) nodules (OR, 19.8; 95% CI, 1.94-202.29; P = .012) and pleural effusion (OR, 5.07; 95% CI, 1.06-24.23; P = .042) at the time that the patient underwent the initial CT were both independent predictors of PZ in the logistic regression analysis of radiological parameters. No difference occurred in the frequency of other CT findings suggestive of pulmonary mold infections (e.g., masses, cavities, halo sign, or air-crescent sign) between the 2 patient groups.

CONCLUSIONS

PZ in immunocompromised patients with cancer could potentially be distinguished from IPA on the basis of clinical and radiological parameters; prospective validation is needed.

Zygomycosis in a Tertiary‐Care Cancer Center in the Era ofAspergillus‐Active Antifungal Therapy: A Case‐Control Observational Study of 27 Recent Cases

BACKGROUND

Anecdotal evidence suggests a rise in zygomycosis in association with voriconazole (VRC) use in immunosuppressed patients.

METHODS

We performed prospective surveillance of patients with zygomycosis (group A; n = 27) and compared them with contemporaneous patients with invasive aspergillosis (group B; n = 54) and with matched contemporaneous high-risk patients without fungal infection (group C; n = 54). We also performed molecular typing and in vitro susceptibility testing of Zygomycetes isolates.

RESULTS

Nearly all patients with zygomycosis either had leukemia (n = 14) or were allogeneic bone marrow transplant recipients (n = 13). The Zygomycetes isolates (74% of which were of the genus Rhizopus) had different molecular fingerprinting profiles, and all were VRC resistant. In multivariate analysis of groups A and C, VRC prophylaxis (odds ratio [OR], 10.37 [95% confidence interval [CI]], 2.76-38.97]; P = .001), diabetes (OR, 8.39 [95% CI, 2.04-34.35]; P = .003), and malnutrition (OR, 3.70 [95% CI, 1.03-13.27]; P = .045) were found to be independent risk factors for zygomycosis. Between patients with zygomycosis (after excluding 6 patients with mixed mold infections) and patients with aspergillosis, VRC prophylaxis (OR, 20.30 [95% CI, 3.85-108.15]; P = .0001) and sinusitis (OR, 76.72 [95% CI, 6.48-908.15]; P = .001) were the only factors that favored the diagnosis of zygomycosis.

CONCLUSIONS

Zygomycosis should be considered in immunosuppressed patients who develop sinusitis while receiving VRC prophylaxis, especially those with diabetes and malnutrition.

Zygomycosis in Qatar: a retrospective review of six cases

Six cases of zygomycosis that were diagnosed at Hamad Medical Corporation over an eleven-year period are retrospectively reviewed. All patients had at least one predisposing condition. Renal transplant and diabetes mellitus were the most common predisposing conditions. Sites of involvement were pulmonary in two patients, rhinocerebral two, rhino-orbital, and cutaneous in one each. The clinical features in patients with rhinocerebral and rhino-orbital involvement were very suggestive of the diagnosis, while patients with pulmonary and cutaneous involvement, the disease was not suspected and was only made after the histopathology or culture results were available. Diagnosis was made premortum in all patients. Diagnosis was confirmed by histopathology in three patients and by culture in the other three. Five of the six patients died. Poor outcome correlated with rhinocerebral and pulmonary involvement, while cutaneous disease was associated with favorable outcome. Therapy with amphotericin B, surgical debridement, and correction of the underlying predisposing condition offers the best chance for survival.

Trichomycete symbiotes of Crozetia seguyi, a primitive black fly

Crozetia is a genus of black flies endemic to the Crozet Islands in the Indian Ocean. No internal symbiotes were previously known from Crozetia species. We report two species of trichomycete symbiotes Stachylina litoralis and Smittium culicisoides from Crozetia seguyi. Larvae of C. seguyi were examined from three sites. The infection rates for St. litoralis was 10.0-33.3% (n=47) of the larvae and Sm. culicisoides was 46.1-85.7% (n=47). No other symbiotes were discovered.

Invasive Zygomycosis in Hematopoietic Stem Cell Transplant Recipients Receiving Voriconazole Prophylaxis

We report 4 cases of invasive zygomycosis in hematopoietic stem cell transplant recipients, all occurring after May 2003, when voriconazole began to be used as antifungal prophylaxis. No cases of zygomycosis had been detected in this population in the 3 years prior to May 2003. All 4 patients were receiving immunosuppressive therapy for presumed graft-versus-host disease. Profoundly immunosuppressed patients receiving voriconazole prophylaxis remain at risk for less-common pathogens that are intrinsically resistant to this agent.

Entomophthoromycosis in South Bengal (Eastern India): a 9 years study

Subcutaneous mycoses caused by the family Entomophthoraceae is very rare type of disease and is being reported sporadically from various Tropical countries including India. Here we report 8 cases of rhinoentomophthoromycosis caused by Conidiobolous coronatus and 7 cases of chronic subcutaneous phycomycosis caused by Basidiobolus ranarum. Cases were detected during a span of 9 years between 1991 to 1999, from 9 districts in and around Kolkata (Eastern India). Former type of lesions were detected among 20 to 65 age group of healthy individuals, predominantly males (7:1). In the latter type, male-female ratio was 2:5, and except for one all cases belonged to below 20 years age group of healthy individuals. Several cases were detected only after examination of repeat biopsy samples. With high degree of clinical suspicion, right approach is needed for laboratory confirmation of diagnosis.

Pediatric gastrointestinal basidiobolomycosis

Basidiobolomycosisis an unusual fungal infection that manifests in the skin and rarely involves other systems including the gastrointestinal tract. We retrospectively reviewed records of six pediatric patients (< or =14 years of age) diagnosed with gastrointestinal basidiobolomycosis from March 2000 to March 2002. Four patients came from the same region, suggesting environmental exposure. Basidiobolomycosis should be considered in the differential diagnosis in pediatric patients presenting with abdominal mass and eosinophilia.

Increase in aspergillosis and severe mycotic infection in patients with leukemia and MDS: Comparison of the data from the Annual of the Pathological Autopsy Cases in Japan in 1989, 1993 and 1997

To study the relationship between the changes in visceral mycoses rates and recently advanced medical care in hematological settings, data on visceral mycosis cases with leukemia and myelodysplastic syndrome (MDS) that had been reported in the Annual of the Pathological Autopsy Cases in Japan in 1989, 1993 and 1997 were analyzed. The frequency rate of visceral mycoses with leukemia and MDS was 27.9% (435/1557) in 1989, 23.0% (319/1388) in 1993 and 22.3% (246/1105) in 1997. In comparing the rate of mycoses in recipients of organ or bone marrow transplantation with that of non-recipients, that of recipients was approximately 10% higher. The predominant causative agents were Candida and Aspergillus, at approximately the same rate as in 1989. The rate of candidosis decreased to one-half that of aspergillosis by 1993. Furthermore, severe mycotic infections clearly increased from 58.9% in 1989 to 75.6% in 1997. Among a total of 1000 cases with mycotic infection in those 3 years, acute lymphatic leukemia and acute myeloid leukemia were the major diseases (40.6% and 34.8%, respectively), followed by MDS (26.1%). The reasons for increased rates of aspergillosis and of severe mycotic infection can be surmised to be: (i) candidosis had become controllable by prophylaxis and by empiric therapy for mycoses with effective antifungal drugs; (ii) the marketed antifungal drugs were not sufficiently effective against severe infections or Aspergillus infections; and (iii) the number of patients surviving in an immunocompromised state had increased due to developments in chemotherapy and progress in medical care.

First description of the disease by Conidiobolus osmodes on Tipula paludosa larvae with the report of a natural epizootic

A new fungal pathogen of Tipula paludosa (Tipulidae: Diptera) larvae, Conidiobolus osmodes (Ancylistaceae: Entomophthorales), was found during a survey of tipulid larval pathogens in Northumbria and Cumbria in England in 1997-1999. The fungus caused an epizootic in a population at Close House during autumn 1999 and spring 2000 with prevalence rising fourfold reaching about 40% in April 2000. The disease development was presented and the fungus was described from naturally infected larvae and artificial cultures.

Entomophthora leyteensis Villacarlos & Keller sp. nov. (Entomophthorales: Zygomycetes) infecting Tetraleurodes acaciae (Quaintance) (Insecta, Hemiptera: Aleyrodidae), a recently introduced whitefly on Gliricidia sepium (Jaq.) Walp. (Fabaceae) in the Philippines

Entomophthora leyteensis Villacarlos & Keller sp. nov., a species of Entomophthorales infecting the whitefly Tetraleurodes acaciae on Gliricidia sepium in the Philippines is described. Disease prevalence monitored weekly for 8 weeks indicated that the fungus could cause 8-31% infection within the whitefly population. Epizootics due to this fungus occurred in Inopacan, Leyte. Sampling live whitefly adults and dissecting them on glass slides for microscopic examination of fungal structures was found to give a better measure of prevalence than actual counts of infected insect cadavers. E. leyteensis is an important mortality factor for T. acaciae. Some speculations on the origin of the fungus are discussed here.

Zygomycosis

Zygomycosis, an uncommon but frequently fatal mycosis caused by fungi of the class Zygomycetes, develops most commonly as an opportunistic disease. Successful therapy involves a combined approach based on early diagnosis, prompt institution of medical therapy, and extensive surgical debridement of all devitalized tissue. Given the rarity of this condition, novel therapeutic strategies have been limited and only tested on an individual basis. The use of high-dose lipid formulations of amphotericin B, prompt reversal of the underlying predisposing condition, and hyperbaric oxygen are the most common strategies that have shown potential value in the treatment of zygomycosis.

[Risk factor for invasive zygomycosis in patients with hematologic malignancies]

Zygomycosis (mucormycosis) is a relatively uncommon infection in immunocompromised patients most often diagnosed in patients with haematological malignancies and neutropenia. Postmortem series demonstrate a high mortality rate up to 80%. Pulmonary involvement mimicking the more frequently diagnosed invasive aspergillosis is the typical clinical presentation. Other risk factors for the development of zygomycosis that have been described in other patient populations include diabetic ketoacidosis, iron overload, use of deferoxamine and steroids. If these factors are also associated with zygomycosis in patients with haematological malignancies has not been described. In a retrospective case-control study including 13 patients with zygomycosis and 13 control patients with the same underlying diseases, without zygomycosis we determined the frequency of various risk factors. Patients with zygomycosis experienced a longer period of neutropenia (17 vs. 13 days) and lymphopenia (23 vs. 20 days). A relapse of their underlying disease was diagnosed more frequently in patients with zygomycosis (7/13 vs. 3/13) as were a diagnosis of diabetes mellitus (6/13 vs. 3/13) and a cardiovascular disease (6/13 vs. 1/13). The previous use of steroids was more frequent in patients with zygomycosis (8/13 vs. 4/13) as was a systemic antifungal prophylaxis with itraconazole (9/13 vs. 4/13). Knowledge of these risk factors may be of benefit in diagnosing and monitoring zygomycosis in patients with haematological malignancies.

Entomophthoromycosis in Maharaj Nakorn Chiang Mai Hospital

OBJECTIVE

To review documented entomophthoromycosis patients at Maharaj Nakorn Chiang Mai Hospital from 1985 to 2001.

MATERIAL AND METHOD

A retrospective review was performed at Maharaj Nakorn Chiang Mai Hospital from 1985 to 2001. Eight cases of entomophthoromycosis were found between 1988 and 1993, with five patients diagnosed as subcutaneous zygomycosis, I GI entomophthoromycosis and 2 rhinofacial zygomycosis.

RESULTS

The subcutaneous zygomycosis group was composed of 5 female patients, aged 7- 77 years. They presented with a painless subcutaneous mass, which was solitary or multiple and most commonly found on the extremities. The duration of disease was between 3 months to 5 years. The cultures grew Basidiobolus ranarum. A case of GI entomophthoromycosis was seen in a 34 year old man, who presented with dyspepsia, multiple intraabodminal masses and peritonitis. Two cases of conidiobolomycosis (rhinofacial zygomycosis) were seen. These two patients were male, 26 and 39 years old, and they presented with unilateral nasal obstruction from a mass at the inferior turbinate. The cultures grew Conidiobolus coronatus.

CONCLUSION

Entomophthoromycosis in the northern part of Thailand is rare. The disease should be differentially diagnosed by a chronic painless tumor. The patients in this review responded very well to the recommended therapy.

Basidioboliasis in anurans in Florida

Members of the genus Basidiobolus, a saprophytic fungus, have been associated with the digestive tracts of a wide variety of amphibians and reptiles. To elucidate the relationship of Basidiobolus sp. with amphibians in central Florida (USA), we document the occurrence of the fungus in the digestive tracts of Bufo terrestris, Buffo quercicus, Hyla femoralis, Hyla cinerea, Hyla gratiosa, Hyla squirella, Osteopilus septentrionalis, and Rana utricularia. Species that occupy terrestrial habitats (B. terrestris, B. quercicus, and R. utricularis) were found to harbor Basidiobolus spp. more frequently (83, 78, and 91%, respectively) than those that occupied a more arboreal habitat (H. cinerea, H. squirella, H. femoralis, H. gratiosa, and O. septentrionalis (50, 56, 55, 56, and 70%, respectively).

Geographical distribution and host range of entomophthorales infecting the green spruce aphid Elatobium abietinum Walker in Iceland

Entomophthora planchoniana and Neozygites fresenii caused infection in populations of the green spruce aphid, Elatobium abietinum, in Iceland. On this aphid species En. planchoniana was exclusively found in the western part of Iceland, while N. fresenii was exclusively found in the eastern part of Iceland. This discrete and nearly nonoverlapping geographical distribution correlates with the distribution of two different populations of El. abietinum found in Iceland. On other aphid species N. fresenii, En. planchoniana, Pandora neoaphidis, and Conidiobolus obscurus were documented throughout the country. Transmission experiments showed that Pa. neoaphidis and En. planchoniana could infect the eastern population of El. abietinum, although they have never been found on this population in nature. This strongly indicates that there is little or no interaction among El. abietinum, other aphids, and their respective entomophthoralean fungi in the field. Furthermore, this study is the first to record epizootics caused by N. fresenii and En. planchoniana in the subpolar region.

Gastrointestinal basidiobolomycosis in Arizona: clinical and epidemiological characteristics and review of the literature

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37--59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3--19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.

Ten years' experience in zygomycosis at a tertiary care centre in India

OBJECTIVE

To define the spectrum of zygomycosis due to mucorales in an Indian scenario.

METHODS

One-hundred and twenty-nine patients with zygomycosis due to mucorales diagnosed at the Postgraduate Institute of Medical Education and Research, Chandigarh, India during 1990-99, were retrospectively analysed regarding the sites of involvement, underlying disease, species of fungi isolated and outcome of therapy.

RESULTS

Higher prevalence rate (19.4%) was observed in 1999. Rhino-orbito-cerebral type (44.2%) was the commonest presentation followed by cutaneous (15.5%) and renal (14.0%) involvement. Disseminated zygomycosis was seen in 11.6% patients. Pulmonary and gastrointestinal zygomycosis were diagnosed in 10.1% and 4.7% patients, respectively. Uncontrolled diabetes mellitus (in 50% of cases) was the significant risk factor in rhino-orbito-cerebral type [odds ratio (OR), 9.3; P<or=0.001) and breach of skin (in 40% cases) in cutaneous zygomycosis (OR, 6.9; P<or=0.01). However, a considerable number of 22 (22.9%) patients were apparently healthy hosts in this series. Forty-five patients (34.9%) of this series were diagnosed only at post-mortem. Among 47 patients where culture was attempted, mucorales were isolated from 25 patients with Rhizopus arrhizus (11 patients) and Apophysomyces elegans (eight patients) as the predominant isolates. Adequate therapy could be provided in 33 patients. A combination of aggressive surgical debridement of necrotic tissue and amphotericin-B was found to be the best treatment protocol as 81.3% patients treated with surgical debridement and amphotericin-B were cured, compared with 46.7% patients treated with amphotericin-B alone.

CONCLUSION

The study highlights the importance of increased awareness for early diagnosis of zygomycosis and aggressive management. The large number of cases in apparently healthy hosts and increased isolation of A. elegans in the present series are important characteristics of this disease in India and requires further evaluation.

[Cutaneous mycoses as a problem of the tropics. II. Subcutaneous tropical mycoses]

Cutaneous mycoses are third among diseases after parasitic and infectious ones that pose problems for persons returning from the tropics. The paper presents semiotics of the following tropical subcutaneous mycoses: sporotrichosis, chromoblastomycosis, maduromycosis, pheohyphomycosis, zygomycosis and lobomycosis.

A review of zygomycosis due to Basidiobolus ranarum

Zygomycosis due to Basidiobolus ranarum (entomophthoromycosis basidiobolae, subcutaneous zygomycosis, subcutaneous phycomycosis, basidiobolomycosis) is a granulomatous infection of the skin and subcutaneous tissues characterized by the formation of fluctuant firm and non-tender swellings, generally on the extremities, trunk and rarely other parts of the body. The causative agent is common in soil, decaying vegetable matter, and the gastrointestinal tracts of amphibians, reptiles, fish and bats. It is presumed that infection is acquired through exposure to B. ranarum following minor trauma to skin or insect bites. The disease usually occurs in children, less often in adolescents and rarely in adults. Males are much more frequently affected than females. Laboratory diagnosis is based on histopathology and culture. The typical histopathological feature is the presence of thin-walled, broad often aseptate hyphae or hyphal fragments with an eosinophilic sheath, frequently phagocytized within giant cells. Basidiobolus ranarum is known to produce several enzymes, e.g. lipase and protease that probably play roles in the pathogenesis of infections caused by this mould. An immunological test has been developed for specific diagnosis of the disease. Though potassium iodide (KI) has been the traditional drug employed in the treatment of infections by B. ranarum, several other drugs, viz amphotericin B, cotrimoxazole, ketoconazole, itraconazole and fluconazole have been successfully tried.