Primary Cutaneous Zygomycosis Research Articles

PRIMARY CUTANEOUS MUCORMYCOSIS IN AN IMMUNOCOMPETENT PATIENT: A CASE REPORT

Zygomycosis is an infrequently encountered locally invasive, aggressive fungal infection that frequently occurs in patients with an underlying immunodeficiency. It is usually diagnosed on histopathology and treated with systemic antifungals. We report a case of 16 years old female who presented with swelling on the dorsum of nose with overlying redness and tenderness. As she did not respond to antibiotics and conventional treatment, computed tomography (CT) scan and fine needle aspiration cytology (FNAC) were performed which revealed an inflammatory lesion. However, her histopathological examination was a surprise for all of us as it came out to be zygomycosis. She was started on oral antifungal, and responded well. Although a rare entity, primary cutaneous zygomycosis should always be kept in mind while evaluating any swelling if it doesn’t improve on conventional treatments and dealt accordingly.

Primary cutaneous zygomycosis in a man with acute myeloid leukemia

Primary cutaneous zygomycosis in a man with acute myeloid leukemia

When you can’t see the wood for the trees. Mucor circinelloides: A rare case of primary cutaneous zygomycosis

A patient with refractory diffuse lymphoma treated for pulmonary invasive aspergillosis developed a concomitant primary cutaneous mucormycosis. The mucormycete was identified by sequencing as Mucor circinelloides. This case confirms the importance of a rapid pathogen diagnosis in immunocompromised patients and the usefulness of molecular methods for identification of rare fungal species.

Primary cutaneous zygomycosis secondary to minor trauma in an immunocompromised pediatric patient: a case report

Zygomycosis is an opportunistic infection generally found in immunocompromised individuals. Herein we present a pediatric patient with primary cutaneous mucormycosis that developed at a site of trauma. Diagnosis and treatment are discussed.

Cutaneous Rhizopus infection at a central venous catheter site in a critically ill renal transplant patient

Invasive fungal infections are increasing in incidence, along with the use of immunosuppressive medications for the prevention of organ transplant rejection, graft versus host disease and treatment of auto-immune disorders. Additionally, the incidence of invasive fungal infections is increasing with the use of new antineoplastic therapies for malignancy, increasing incidence of diabetes mellitus, expanded use of broad-spectrum antimicrobial therapy and with an aging population with chronic medical problems such as chronic renal failure, chronic obstructive pulmonary disease and HIV. We present a case of primary cutaneous zygomycosis at the insertion site of a central venous catheter in a 45-year-old renal transplant patient admitted for acute pancreatitis. In the critical care setting, clinicians must retain a high index of suspicion for invasive fungal infections in immunocompromised individuals to ensure early diagnosis and provide aggressive medical and surgical intervention. Liposomal amphoterin B is the first line antimicrobial therapy, and reduction or discontinuation of immunosuppressive therapy should be considered. Currently there are no consensus opinions or recommendations for routine, scheduled replacement of central venous catheters to prevent infections, even in immunosuppressed patients.

Cutaneous zygomycosis

Cutaneous zygomycosis is a fungal infection caused by zygomycetes that affects the skin. It occurs in uncontrolled diabetic patients and immunosuppressed individuals. It has 2 clinical forms: primary cutaneous zygomycosis and secondary cutaneous zygomycosis. The first is characterized by necrotic lesions and the fungus is usually inoculated by trauma. If diagnosed early, it generally has a good prognosis. Secondary zygomycosis is usually a complication and extension of the rhinocerebral variety that starts as a palpebral fistula and progresses to a necrotic lesion with a poor prognosis. The diagnosis is made by identification of the fungus by direct KOH examination, culture, and biopsy. Treatment for the primary disease is surgical debridement plus amphotericin B. The secondary type is treated with amphotericin B and/or posaconazole.

Primary Cutaneous Zygomycosis in India

Cutaneous zygomycosis remains underdiagnosed despite being frequently encountered. Delay in the diagnosis contributes to delay in treatment, and a resultant high morbidity and mortality. A retrospective analysis of the reported cases of cutaneous zygomycosis from India was made using various search engines and cross-referencing from available manuscripts. A total of 42 publications from India on the topic were identified, since the first reported case of primary cutaneous zygomycosis by Veliath et al. (1976). There are 130 described cases of cutaneous zygomycosis with an overall mortality of 35%. The commonest zygomycete identified was Apophysomyces elegans, and the commonest predisposing factor was breach of the skin. Surprisingly, diabetes was reported only in 36 cases (27.69%). It is important to be aware of this unusual but fatal infection in order to manage it properly and have a good outcome.

Fatal Primary Cutaneous Zygomycosis Caused bySaksenaea vasiformis:Case Report and Review of Literature

Primary cutaneous zygomycosis caused by Saksenaea vasiformis is rare. Such infections usually are not suspected, and delay in their diagnosis and treatment results in a poor outcome. Case report and review of the relevant English-language literature. A fulminant cutaneous infection developing after intramuscular injection in the gluteal region of a 60-year-old female patient is described. The hallmark of this uncommon infection was the rapidity with which the skin and subcutaneous tissues of the right gluteal and lower abdominal regions underwent necrosis. The infection remained undiagnosed for nearly two weeks, leading to a fatal outcome. Awareness of the fact that fungi can also be the cause of cutaneous infections, as well as a high index of suspicion in patients who do not respond to conventional therapy, should help in the early diagnosis and management of such infections and may help in reducing the mortality rate.

Apophysomyces variabilisInfections in Humans

To the Editor: The fungus Apophysomyces elegans (order Mucorales) is a thermotolerant species that causes severe infections among humans. In contrast to other fungi that cause zygomycosis, which have a worldwide distribution and are rarely found in immunocompetent hosts, A. elegans has been reported mainly in areas with warm climates as an emerging pathogen that causes mostly cutaneous infections after injury to the skin (1). This fungus was discovered in 1979 (2) and until recently was considered the only species in the genus. A polyphasic study of clinical and environmental strains of A. elegans, including analysis of several genes, showed that the genus contained 4 well-characterized species (3). Of 16 isolates tested in this study, only 2 from soil in India were A. elegans. Most of the isolates were A. variabilis. The incidence of A. variabilis in humans is unknown and difficult to ascertain because most cases had isolates that were not properly preserved. These fungi usually cause necrotizing fasciitis, but rhino-orbito-cerebral or renal infections have also been reported (1). Whether these infections are produced by different Apophysomyces spp., have different responses to antifungal drugs, or have differences in virulence is unknown. To assess incidence of Apophysomyces spp. in a tertiary hospital (Government Medical College Hospital, Chandigarh, India), which usually receives patients with zygomycosis, a retrospective study was conducted during November 2001–April 2009. Nine patients were identified as having primary cutaneous zygomycosis. For 4 patients, fungal isolates were morphologically identified as A. elegans. A description of clinical findings, their management, and outcomes for these 9 patients has been reported (4). The 4 isolates were sent to the Universitat Rovira i Virgili (Reus, Spain) for molecular analysis. The internal transcribed spacer region of these isolates was sequenced and compared with those of type strains of Apophysomyces spp. Fungi were identified by morphologic (Figure, panel A) and molecular analysis as A. variabilis (99.6%–99.7% sequence identity with sequence of type strain CBS 658.93 [{type:entrez-nucleotide,attrs:{text:FN556436,term_id:306480963}}FN556436]). GenBank accession nos. of the 4 isolates are {type:entrez-nucleotide,attrs:{text:FN813491,term_id:307133352}}FN813491, {type:entrez-nucleotide,attrs:{text:FN813490,term_id:307133351}}FN813490, {type:entrez-nucleotide,attrs:{text:FN556442,term_id:306480968}}FN556442, and {type:entrez-nucleotide,attrs:{text:FN813492,term_id:307133353}}FN813492. Another patient was also infected with A. variabilis fungi. The patient was a 45-year-old woman with diabetes from Derabassi (Punjab), India, who was hospitalized because of swelling in her right breast and blackening of overlying skin. A diagnosis of right breast gangrene was made. Therefore, local debridement of the swelling was conducted, and tissue samples were tested by microbiologic culture and histopathologic analysis. A KOH wet mount showed broad aseptate hyphae with right-angled branching. The fungal isolate was tentatively identified as A. elegans. Histopathologic analysis confirmed a diagnosis of zygomycosis. The patient was treated under local anesthesia by debridement of infected tissue and some of the healthy surrounding tissue (Figure, panel B). However, an antifungal regimen could not be given because she had disturbed renal function. Her condition deteriorated, septicemia was observed, and she died from sudden cardiac arrest on the sixth day after admission. The fungal isolate was also identified as A. variabilis (98.9% identity, GenBank accession no. {type:entrez-nucleotide,attrs:{text:FN556443,term_id:306480969}}FN556443). Although most cases of infection with A. variabilis fungi have been reported in India (5), infections with this fungus may have a wider distribution. A recent study demonstrated that this species represented 0.5% of fungi of the order Mucorales isolated from clinical samples in the United States (6). Furthermore, a high mortality rate and the fact that most of these infections involve otherwise healthy patients make this a serious infection. The number of infections with Apophysomyces spp. is underestimated because these fungi do not usually sporulate on standard fungal culture media used in clinical laboratories. These fungi require special nutrient-deficient growth medium (Czapek agar), a high temperature in comparison to other human pathogens (37°C–42°C), and prolonged incubation (7–10 days) (7). A difference in mortality rate was observed when we compared patients in our study (80%) with those reported by Chakrabarti et al. (5) (28.5%) in India, even though treatment was generally similar, i.e., local debridement and amphotericin B. Other differences in our study were that the infection in 4 patients was preceded by intramuscular injection, and these 2 patients had diabetes mellitus. In conclusion, A. variabilis is an emerging pathogenic fungus that can cause rapid and fatal infections in humans. As more isolates of Apophysomyces fungi become available, molecular typing studies must be conducted to better understand the epidemiology and distribution of different Apophysomyces spp. Figure A) Sporangiophore (center) and sporangiospores of Apophysomyces variabilis fungi. Scale bar = 10 μm. B) Clinical manifestations in a woman infected with A. variabilis fungi in the upper part of the chest and the breast. A color version of this ...

Primary Cutaneous Zygomycosis Caused byRhizomucor variabilis:A New Endemic Zygomycosis? A Case Report and Review of 6 Cases Reported from China

We report a case of primary cutaneous zygomycosis caused by Rhizomucor variabilis and review 6 cases reported from China that share similar features and are different from those cases caused by other species of Mucorales. It is noteworthy that all 6 of the cases were observed in 3 adjacent provinces of eastern China.

Primary cutaneous zygomycosis due toAbsidia corymbiferain a patient with cutaneous T cell lymphoma

A slowly enlarging arm ulcer appeared in a 61-year-old man with cutaneous T cell lymphoma. Skin biopsy revealed aseptate hyphae and nodular small/medium-sized pleomorphic CD4(+) T cell infiltration. Cultures yielded Absidia corymbifera which was identified by phenotypic and molecular methods. Since a thorough examination did not detect organ involvement, the patient was diagnosed as having primary cutaneous zygomycosis. This is the first case report of cutaneous zygomycosis caused by A. corymbifera in a patient with primary cutaneous CD4(+) small/medium-sized pleomorphic T-cell lymphoma. Other cases of primary cutaneous zygomycosis caused by A. corymbifera are also reviewed.

Post-traumatic Lethal Form of Primary Cutaneous Zygomycosis in a Healthy Young Patient and Review of the Literature

Abstract Zygomycosis is an invasive disease caused by fungi in of the class Zygomycetes. Primary cutaneous zygomycosis is uncommon. We report a case of post-traumatic most lethal form of cutaneous zygomycosis (gangrenous cellulitis), which closely resembles necrotizing fasciitis in a young healthy male patient with polytrauma. Multiple surgical debridements, skin grafting, and intravenous antifungal therapy were necessary to ultimately eradicate the infection. The early diagnosis by tissue culture and histopathology study is mandatory to successfully treat this condition.

Post-traumatic Lethal Form of Primary Cutaneous Zygomycosis in a Healthy Young Patient and Review of the Literature “Arabic Abstracts”

Post-traumatic Lethal Form of Primary Cutaneous Zygomycosis in a Healthy Young Patient and Review of the Literature “Arabic Abstracts”

Cutaneous zygomycosis: A possible postoperative complication in immunocompetent individuals

Fungi in the class of zygomycetes usually produce serious infections in diabetics and immunocompromised hosts. Cutaneous zygomycosis is a less common form, with an unpredictable extent of anatomical involvement and clinical course. Here, we report two cases of primary cutaneous zygomycosis as postoperative complications in otherwise healthy females. Zygomycosis was suspected and specimens from the surgical debridement were examined by microbiological and histopathological studies for confirming the clinical diagnosis. Rapid diagnosis, liposomal amphotericin B, and proper debridement of affected tissue are necessary to avoid a fatal outcome.

Primary Cutaneous Zygomycosis in an Immunodeficient Infant

We report a case of primary cutaneous zygomycosis caused by Rhizopus species in an infant with a hematological malignancy. Multiple surgical debridements, skin grafting, and intravenous antifungal therapy were necessary to ultimately eradicate the infection. Zygomycotic infections are an emerging concern in immunocompromised patients because of their increased incidence as well as their potential to cause substantial morbidity through both emotional distress and impaired functionality. Because resection is a cornerstone of treatment for zygomycosis, the authors anticipate a growing need for plastic surgery involvement for both surgical debridement with limb and tissue-sparing procedures, and for reconstructive options that effectively treat the disease while preserving both function and esthetics. The plastic surgery literature is reviewed regarding surgical and reconstructive options for this population of patients. This case demonstrates the important role plastic surgeons play in the multidisciplinary treatment of zygomycotic and other opportunistic cutaneous infections.

Primary Cutaneous Zygomycosis in a Burns Patient: A Review

Cutaneous zygomycosis is an uncommon but potentially fatal disease. An illustrative case is used to highlight the difficulties in managing these burns patients followed by a review of the literature with special emphasis on the surgical management and outcomes in these patients. English language articles were identified using the MEDLINE database from 1966 to 2006, using key words zygomycosis and mucormycosis. The set was limited to humans and cutaneous disease. All articles (n = 173) were reviewed with special consideration for articles (n = 28) post an extensive review of cutaneous zygomycosis in 1993 by Adam et al. Key clinical features, risk factors, microbiological diagnostics, medical and surgical treatment modalities, outcomes, and prognosis were extracted. In contrast to all overall zygomycosis, cutaneous zygomycosis is associated with immune competency in 50% of cases. Diagnosis remains difficult with extensive and sometimes multiple biopsies confirming the presence of a fungus. Although there are no randomized controlled trials on best care, documented treatment options providing survival benefits include antifungal therapy or surgical debridement. Multiple debridements are routine with amputation not an uncommon scenario. Infection may still progress, despite these aggressive measures. Treated patients with localized cutaneous zygomycosis still have a mortality rate of 31%. Cutaneous zygomycosis is an exceedingly difficult disease to manage with limited evidence to guide management. This review offers some insight to burns surgeons and other health professionals to help provide best practice for patients in the future.

Primary Cutaneous Zygomycosis in Two Immunocompromised Children

Zygomycosis, often referred to as ''mucormycosis'' or ''phycomycosis,'' is a rapidly progressive fungal infection which usually occurs in immunocompromised individuals, and is characterized by soft tissue destruction and invasion of blood vessels. The rare and easily misdiagnosed primary cutaneous form may present as a superficial erosion with a painless, gradual onset and slow progression of symptoms or a gangrenous, necrotic ulceration due to rapid tissue and vascular invasion. With the latter form, the mortality rate among affected individuals is high even after aggressive surgical debridement and amphotericin B administration, emphasizing the importance of early recognition and proper diagnosis. We present two instances of gangrenous cutaneous zygomycosis in immunocompromised children and review the literature with regard to etiology, diagnosis and treatment, highlighting the pediatric population.

Mucor circinelloides Was Identified by Molecular Methods as a Cause of Primary Cutaneous Zygomycosis

A case of primary cutaneous zygomycosis caused by Mucor circinelloides is described. Histopathology showed typical hyphae along with chlamydospores. The isolate was identified by molecular and phenotypic methods. The utility of sequence analysis of the internal transcribed spacer region is highlighted; however, further studies are needed to assess species genetic heterogeneity.

Cutaneous zygomycosis due to Rhizopus oryzae in a patient with acute lymphoblastic leukemia

We report herein a case of primary cutaneous zygomycosis caused by Rhizopus oryzae in a 7-year-old girl with acute lymphoblastic leukemia (ALL) receiving intensive chemotherapy. The diagnosis was based on observation of hyphal elements in cutaneous biopsy and isolation of the fungus in culture. The patient responded to surgical intervention and treatment with amphotericin B.

Successful treatment of a primary cutaneous zygomycosis caused by Absidia corymbifera in a premature newborn.

Mucormycosis (zygomycosis) normally occurs among individuals with predisposing factors such as prematurity, use of broad spectrum antibiotics, metabolic acidosis or advanced stages of immunosuppression. There have been reports of sporadic cases of cutaneous mucormycosis related to predisposing skin lesions and contact with contaminated material such as adhesive bandages and tongue depressors placed close to intravenous catheter insertion sites. We report successful treatment of a case of Absidia corymbifera infection with the combination of amphotericin B and surgical debridement of the affected area.