Difficulties in diagnosing primary cutaneous mucormycosis: Excluding mycobacterium other than tuberculosis

Primary cutaneous mucormycosis (MM) is a rare fungal infection of childhood and is most often encountered in immunocompromised patients. It is a potentially lethal opportunistic fungal infection with rapid progression and high mortality. A report of cutaneous MM involving the head region is very rare. We herein report a case of primary cutaneous MM in a malnourished patient. The infection progressed rapidly, and the infant died from infection. The diagnosis was made at postmortem examination. Early diagnosis and surgery should be undertaken to prevent fatal outcome, and complete study of the etiologic agent must be carried out in all cases.

Emergence of Mucormycosis during COVID-19 Pandemic and Dermatological Manifestations.

Mucormycosis is a rare but potentially lethal fungal infection that can affect any organ system, especially in immune-compromised individuals. Cutaneous manifestations comprise < 10% of cases of mucormycosis. The hallmark of mucormycosis is angioinvasion followed by thrombosis and necrosis of infected tissues. Here, we report a case of primary invasive cutaneous mucormycosis in a 52-year-old male with uncontrolled diabetes who presented with necrotising fasciitis of the right leg. Ulcer edge biopsy and special stain examination were consistent with invasive cutaneous mucormycosis. Timely antifungal initiation and wide local necrosectomy saved the life and limb of our patient.

Mucormycosis of the anterior abdominal wall is an uncommon disease and it is very rare to find this disease in immunocompetent, non-diabetic patients which usually affects patients with trauma, with contaminated wounds, patients with underlying malignancies or patients with immunocompromised state, e.g., diabetics. We herein report a case of primary cutaneous mucormycosis in an immunocompetent and non-diabetic patient. Our patient was a 48-year-old female, executive by profession. She was diagnosed to have cutaneous mucormycosis of the anterior abdominal wall, and was managed with multiple debridements of the wound and intravenous amphotericin B therapy. She was administered a total of 1500 mg of liposomal amphotericin B and when fully healed, split skin grafting was done. We would like to emphasize the importance of high index of suspicion and early start of therapy in a condition with high rate of mortality.

A 50-year-old female farmer presented with nodules,plaques and ulcers on as well as erythematous swelling of the right upper limb for six years,plaques on the right buttock for two years and on the fight cheek for one year.She had been treated with terbinafine and itraconazole,but no obvious improvement was achieved.Broad,septated and right-angled branching hyphae were found by both routine pathological examination and periodic acid-Schiff (PAS) staining of the lesional tissue from the right upper limb and buttock.The fungus was identified as Mucor irregularis by culture and molecular biological approaches,and the patient was diagnosed with primary cutaneous mucormycosis and given intravenous amphotericin B with the total dose being 1 060 mg.Subsequently,the plaques on and swelling of the right cheek and buttock gradually regressed,and the plaques on,swelling and necrosis of the right dorsal hand subsided with shedding of black crusts and formation of scar.The repeated fungal culture of lesional tissue on the right limb was negative.The patient was followed for one year and no recurrence was observed. Key words: Mucor irregularis; Rhizomucor variabilis; Amphotericin B; Primary cutaneous mucormycosis

Cutaneous mucormycosis is an uncommon disease and it usually affects immunocompromised, diabetic, and trauma patients with contaminated wounds or patients with underlying malignancies. It is very rare to find this disease in immunocompetent, nondiabetic patients. We herein report a case of primary cutaneous mucormycosis in an immunocompetent and nondiabetic patient. Our patient was a 50-year-old veterinary doctor. He was diagnosed to have cutaneous mucormycosis of the anterior abdominal wall, and was treated with multiple debridements of the wound and intravenous amphotericin B therapy. He received a total of 1000 mg of amphotericin B. A high index of clinical suspicion and early institution of therapy in the form of surgical debridements and antifungal drugs are required to achieve a successful outcome.

Mucormycosis of the head and neck region is a rare but aggressive fungal infection that usually involves immunocompromised patients. More infrequently, this infection can also occur in people with no otherwise known underlying immunological deficit. This rarity usually causes a delay in diagnosis and may severely decrease the chance of survival in these patients. In this study, we present an extreme case of mucormycosis in an immunocompetent patient. By conducting a thorough review of the literature, we aim to increase our knowledge on this matter. Our goal is to improve diagnosis and start treatment at an earlier stage. Our patient was a 31-year-old man who presented with bilateral face numbness, neck pain, headache, and a necrotic palatal lesion 45days after a dental root canal procedure. There was extensive involvement of facial and skull base bony and soft tissues. Through two debridement sessions and intravenous antifungal treatment, the patient was discharged with near-complete disease resolution. We identified 48 cases in the literature that matched our study criteria. We searched the current literature for proven cases of mucormycosis in the head and neck region who didn't have any underlying disease. We extracted their data and added the data of our patient. Then, we re-analyzed them using descriptive analysis, chi-square, and binary logistic regression to better understand the different factors for survival and disease burden in these patients. 49 patients were analyzed in this study. The mean age was 46.93 ± 15.75 (min 16 and max78 years old). The most prevalent subsite to be involved was the sino-nasal mucosa, followed by the surrounding soft tissues and the orbit. While both orbit and intracranial tissue involvement differed significantly between surviving and deceased patients, only intracranial tissue involvement could be used to predict survival. The overall survival rate was 91.8%. Although very rare, mucormycosis can occur in immunocompetent patients. Physicians should consider mucormycosis when faced with refractory conditions and unusual symptoms such as exposed bones, facial numbness, headaches, and intractable pain. Complementary imaging (CT scan with or without MRI) and histopathological examination are critical for timely diagnosis or exclusion of this potentially fatal yet treatable disease.

Primary cutaneous mucormycosis is a rare entity that affects more frequently extremities of immunosuppressed patients and may be gradual in onset or fulminant. An 83-year-old female with diabetes mellitus presented a nodular lesion in the forearm, which had progressed during one month. Clinically, as the lesion was indolent and followed a linear trajectory, a superficial phlebitis was suspected but later ruled out. Skin blood cultures were negative. Skin biopsy showed a necrotic panniculitis with isolated ghost adipocytes and presence of irregularly branched hyphae involving dermis and some vessels that could be stained with PAS and Grocott, thus leading to the diagnosis of primary cutaneous localized mucormycosis. This case is noteworthy as indolent course in primary cutaneous mucormycosis with vascular involvement is rather rare. Even with a negative culture, R. Variabilis is a candidateetiologic agent as it usually presents a chronic evolution. Histopathologically, most panniculitis related to fungal infection are reportedas pancreatic panniculitis mimickers. In our case, only scarce ghost adipocytes were found and the main histopathological findings were a lobular panniculitis with vasculitis and an extensive basophilic necrosis. Thus, these histopathologic findings should raise suspicion of infection related-panniculitis, and PAS and Grocott stainings should be performed to rule out fungi.

Primary cutaneous mucormycosis is a very uncommon manifestation occurring most often in diabetics or following trauma. We herein present a case of primary cutaneous mucormycosis of the hand caused by Rhizopus microsporus in an immunocompetent patient. This is the second such reported case in the literature.

Primary cutaneous mucormycosis is a rare but often lethal severe fungal infection, which usually occurs in immunocompromised patients. We report a case of primary cutaneous mucormycosis caused by Mucor irregularis in an elderly patient. Seven months after the surgical dissection of the involved skin, cutaneous mucormycosis recurred at the peripheral edge of the skin graft. Shortly subsequent to the administration of liposomal amphotericin B, the remaining skin lesion was excised again. M.irregularis is rarely but increasingly reported as a cause of mucormycosis in immunocompetent individuals, especially in Asian farmers. M.irregularis may be largely disseminated in the soils of Asia and thus the trivial trauma at the time of farm work may be a trigger for the onset. These cases tend to leave severe cosmetic damage even in healthy individuals, although the vital prognosis is not affected.

Introduction: Mucormycosis, a rare and life-threatening infection, is caused by microorganisms of the Mucorales order. It affects almost exclusively immunocompromised and diabetic patients, requiring extensive surgical debridement and prolonged antifungal therapy. Discussion/Results: We report the case of a 26-year-old immunocompetent woman, presenting with cutaneous mucormycosis after suffering blunt force trauma. This rare occurrence of mucormycosis in an immunocompetent patient reinforces the importance of elevated clinical suspicion and early initiation of adequate surgical and antifungal treatment. Conclusion: Mucormycosis is a challenging condition with potentially devastating consequences. Timely diagnosis and appropriate management are vital to mitigate the morbidity and mortality associated with this condition.

We report a rare case of primary cutaneous mucormycosis caused by Rhizopus oryzae that occurred in an immunocompetent trauma patient. The patient had encrusted erythematous plaques with pustules on the left shin, which had been abraded in a traffic accident. Histologic examination revealed widespread granulomatous inflammation and characteristic broad, non-septate hyphae with right-angle branching in the dermis. The infection was cured with intravenous amphotericin B therapy.

To report a rare case of primary cutaneous mucormycosis (PCM), complicating securing of the endotracheal tube with adhesive tape. A 39-yr-old woman with systemic lupus erythematosus (SLE) developed four annular, punched out ulcers with a necrotic centre and elevated border in a linear distribution over the left cheek, under the tape securing the endotracheal tube. A tissue biopsy revealed broad, branching, nonseptate hyphae found in epidermis and dermis consistent with mucormycosis, best demonstrated with silver staining. Cultures were positive for Rhizopus species. Treatment with iv amphotericin B was successful. Because of the rarity of the disease and the difficulty of culturing the causative organism, diagnosis of mucormycosis is often elusive. Tissue biopsy and microscopic visualization of nonseptate hyphae with right-angled branching are the only methods for making the diagnosis. Skin biopsy of new ulcerative or plaque-like lesions should be obtained in immunocompromised patients. Early diagnosis and prompt treatment are critical for favourable outcomes in PCM.

We present a case of primary cutaneous mucormycosis in a patient with bone marrow failure secondary to paroxysmal nocturnal haemoglobinuria (PNH). A 60-year-old male patient with a history of PNH, complicated to a severe aplastic anaemia, presented to the emergency department complaining of papules on the lower limbs that rapidly turned into necrotic plaques within 2 months. Histopathological examination showed granulomatous and suppurative dermatitis with tissue necrosis and the presence of non-septate hyphae. Molecular identification was achieved by amplification and sequencing of the 18S-ITS1-5.8S-ITS2-28S rRNA region using the polymerase chain reaction. The sequence showed 100% identity with Rhizopus arrhizus. The patient received treatment with liposomal amphotericin B and surgical debridement. Nonetheless, the patient suffered from severe low red blood cells and platelets and also underwent septic shock; he died 6 days after admission to the hospital. Mucormycosis in the setting of immunosuppression is challenging. Upon suspicion of a diagnosis, immediate treatment is required. Adjunctive therapies may be considered; however, the case fatality rate remains high.

Cutaneous mucormycosis is a rare opportunistic infection caused by zygomycetes that can be rapidly fatal if unrecognized. We describe the clinical, histopathological, fungal and molecular features of a case of gangrenous cutaneous mucormycosis. The patient presented with great necrosis on his right forearm at the site of detained intravenous cannula needle. He had type II diabetes and chronic renal insufficiency. KOH mount of black eschar showed many broad, aseptate fungal hyphae with right-angle branching. PAS staining of the tissue sample revealed similar broad hyphae in the dermis and cutis. Fungal culture and ITS sequence analysis identified this fungus as Rhizopus oryzae. As no organ involvement was detected, the patient was diagnosed with primary cutaneous mucormycosis. Considering the poor state of the patient, complete excision of the infectious tissue was performed without skin graft instead of amputation. At the same time, intravenous liposomal amphotericin B was given, starting from a small dosage and increased to a total dosage amount of 5.45 g. The wound recovered well with granulation. We emphasize that early recognition and prompt therapy including the control of the primary diseases were important. In this article, we also reviewed the features of primary cutaneous mucormycosis reported in China over the last 20 years.