Necrotising fasciitis due to Absidia corymbifera in wounds dressed with non sterile bandages.

We present three cases of Absidia corymbifera necrotising fasciitis presenting to our centre within 1 month of each other. All patients had wound dressings with non sterile crepe bandages at peripheral centres. One patient was lost to follow-up, another improved on timely antifungal therapy, while the last patient succumbed to disseminated infection. We propose that traumatic and deep wounds be dressed with sterile roller bandages to prevent outbreaks of wound zygomycosis.

[Zygomycosis (mucormycosis) in patients with haematologic malignancy]. / Zygomycosis (mucormycosis) hos patienter med malign hæmatologisk lidelse.

Zygomycosis is an invasive and increasingly emerging life-threatening infection. Diabetes is the most common risk factor; however, zygomycosis has increased among patients with haematologic malignancy, which is now the second most common risk factor with an incidence of 16%. Rapid diagnosis and treatment are essential for patient survival. In the Danish literature, only a few cases have been reported. We present two cases of zygomycosis, both with a fatal outcome, and we discuss the pathogenesis and treatment of invasive zygomycosis.

Lichtheimia corymbifera subcutaneous infection successfully treated with amphotericin B, early debridement, and vacuum-assisted closure.

Lichtheimia corymbifera (syn. Absidia corymbifera, Mycocladus corymbifer) is an ubiquitous cosmopolitan mold that can cause primary cutaneous and deep tissue infection in healthy individuals. We report a subcutaneous L. corymbifera infection in a 13-year-old immune-competent child, with a severe traumatic injury, with a successful outcome after early diagnosis and treatment with lipid amphotericin B, early debridement, and vacuum-assisted closure (VAC).

Invasive zygomycosis in patients with graft-versus-host disease after allogeneic stem cell transplantation.

Invasive mold infections are a threat to immunosuppressed patients such as patients with graft-versus-host disease (GVHD) after allogeneic stem cell transplantation (SCT). Up to 10% of SCT recipients develop invasive aspergillosis (IA). Invasive zygomycosis (IZ) may occur during treatment against IA. Here we report 4 SCT patients with GVHD diagnosed with IZ. All patients had received myeloablative hematopoietic SCT and developed chronic GVHD requiring systemic immunosuppression. Underlying diseases were acute lymphocytic leukemia (2), osteomyelofibrosis, and multiple myeloma. All patients had developed pulmonary infiltration that led to initiation of antifungal therapy. Treatment for IA was voriconazole, caspofungin, or itraconazole. Organs involved with zygomycosis were lung, nasal sinus, skin, and kidney. Treatment with liposomal amphotericin and posaconazole was initiated in all patients, and 2 patients also had surgical debridement as well. Despite intensive treatment, no patient survived. IZ is becoming more common in patients with GVHD on successful treatment for IA. Even non-specific symptoms are suspicious in this group of patients and need to be evaluated by vigorous diagnostics. Despite effective antifungals and surgical intervention, the prognosis is grim in patients with active GVHD, as immunoreconstitution is mandatory for successful management.

Disseminated zygomycosis with involvement of the central nervous system.

Zygomycosis of the central nervous system (CNS) can manifest in three distinct clinical forms, as rhinocerebral zygomycosis, as disseminated zygomycosis with CNS involvement, and as isolated cerebral zygomycosis. We present a case of a 2-year-old boy with leukaemia and disseminated zygomycosis, caused by Absidia corymbifera, involving the brain, spinal cord, lung and liver. The child received treatment with liposomal amphotericin B and posaconazole for 6 months. Although the lesions of the lungs and liver resolved, those of the CNS persisted and the child is in a vegetative state. A review of the literature after 2004 identified ten additional cases of disseminated zygomycosis with cerebral involvement, all but one of which had concurrent lung infection. The most common underlying disease in these cases was haematological malignancy and the mortality rate was 70%. Disseminated zygomycosis with cerebral involvement is a fatal disease. Early recognition and prompt intervention with combined medical and surgical treatment may improve the outcome.

Outbreaks of zygomycosis in hospitals.

Zygomycosis refers to a group of uncommon and frequently fatal mycoses caused by fungi of the class Zygomycetes, the organisms of which are usually found in decaying organic matter. Disease can be transmitted by the inhalation of spores or by direct inoculation on disrupted skin or mucosa. For rare diseases such as zygomycosis, two or more cases occurring in a short time should be investigated as a probable epidemic. Twelve hospital outbreaks and two pseudoepidemics caused by Zygomycetes have been cited in the English literature. The first epidemic was recorded in 1977 and the last in 2008. Outbreaks have been reported in the USA, the UK and elsewhere in Europe. Cases have included cutaneous, disseminated, pulmonary and rhinocerebral disease. Species identified have included Rhizopus arrhizus, Rhizopus rhizopodiformis, Rhizopus microsporus, Rhizopus spp., Absidia corymbifera and Rhizomucor pusillius. Sources of infection have included Elastoplast adhesive bandage rolls, ventilation systems, wooden tongue depressors, karaya (plant-derived adhesive) ostomy bags, and water damage to a linen store and patient shower room. Patients have included cardiosurgery patients, renal transplant recipients, orthopaedic patients, adult leukaemia patients, intensive care unit neonates, immunocompromised haematology patients, and burn unit patients. Although zygomycosis outbreaks in the hospital environment are infrequent, a high index of suspicion should exist if necrotic lesions appear in proximity to a postoperative wound. Direct tissue examination and tissue culture and histopathology must be routinely performed.

Primary cutaneous zygomycosis due to Absidia corymbifera in 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.

Acute refractory hyperkalaemia and fatal cardiac arrest related to administration of liposomal amphotericin B.

A 36-year-old male with acute myeloid leukaemia was treated with liposomal amphotericin B for a breakthrough fungal infection with Absidia corymbifera during voriconazole and caspofungin therapy for invasive pulmonary aspergillosis. Four episodes of hyperkalaemia developed with a highly probable relation to infusion of liposomal amphotericin B, of which the last episode was characterised by severe, refractory hyperkalaemia and fatal cardiac arrest. The available literature on severe hyperkalaemia and cardiac arrest during administration of both conventional and liposomal amphotericin B is reviewed here and revealed only four similar cases. The most likely mechanism of toxicity is the release of potassium from a variety of mammal cells including erythrocytes and endothelial cells. Whether prevention of toxicity can be established by decreasing the infusion rate is unclear but conceivable.

Palatal zygomycosis: experience of 21 cases.

OBJECTIVE: To present a clinical report of palatal zygomycosis, its epidemiological, mycological features, and our treatment experience. DESIGN: Retrospective report. SUBJECTS AND METHODS: This is a 25-year long retrospective trial of clinically and mycologically proven cases of zygomycosis. Some patients underwent a biopsy of the palatal lesion and autopsy. This study reports the treatment experience with amphotericin B alone and in combination with itraconazole and fluconazole. RESULTS: Twenty-one cases (18.75%) of zygomycosis with palatal involvement were included in the study, from a total of 112 cases screened. Mean age was 36.5 years, with 18 adults and three children. The associated pre-disposing factors were: ketoacidotic diabetes (five type-1 and 15 type-2), and acute leukaemia in one patient. The clinical varieties were as follows: 19 cases of rhinocerebral (RC) involvement and two disseminated cases. Palatal ulcers occurred in 3/21 early cases (14.3%) and in 16/21 cases after the nasal involvement. All patients received amphotericin B; in four patients, it was combined with itraconazole and four with fluconazole. Clinical and mycological cure was achieved in 4/21 patients (19.04%). CONCLUSION: Zygomycosis with palatal involvement occurs in around 18% of cases, usually associated with RC modalities; it has an acute and generally lethal course.

Necrotizing (malignant) otitis externa: an unusual localization of mucormycosis.

Malignant otitis externa (MOE) is a severe infection of external auditory canal and skull base. A 17-year-old diabetic girl was admitted with diabetic ketoacidosis. Cellulitis of her right ear occurred on the second day of hospitalization and a black necrotic scar in the same region appeared on the next day. The lesion rapidly invaded to right side of neck and surrounding tissue of the patient. Therefore, antimycotic therapy was started. Unfortunately the patient died on seventh day of hospitalization because of probably extensive fungal invasion. Physicians should suspect MOE connected to mucormycosis especially in patients with cutaneous lesions of ear unresponsive to antibiotic therapy.

Post-traumatic and post-surgical Absidia corymbifera infection in a young, healthy man.

Absidia corymbifera infection in a healthy individual is rare. Most of the infection occurs in immunocompromised patients or diabetic patients. Cutaneous and subcutaneous mucormycosis have been increasingly reported in the literature as a result of massive trauma with contaminated wounds. We present a case of cutaneous mucormycosis in a healthy, young patient after surgical amputation for a crush injury of the leg. We also highlight the importance of the high index of clinical suspicion in the diagnosis and treatment of this fungal infection in the hype of methicillin-resistant Staphylococcus aureus (MRSA) infection in hospital setting these days. Despite an initial life-saving amputation, it was inadequate to ensure the eradication of A. corymbifera infection. A second amputation was required with parenteral liposomal amphotericin B to achieve a satisfactory cure.

Rhinocerebral zygomycosis in a young girl undergoing allogeneic stem cell transplantation for severe aplastic anaemia.

We report on a 10-year-old girl with severe aplastic anaemia who developed rhinocerebral infection caused by Absidia corymbifera and a possible co-infection caused by Alternaria alternata. Despite prolonged neutropenia, therapy with liposomal amphotericin B and posaconazole improved the clinical condition. Subsequently, the girl underwent allogeneic haematopoietic stem cell transplantation (HSCT) for the underlying disease, but the fungal infection remained under control with the antifungal treatment. No severe side effect of the antifungal drugs was noted. Unfortunately, the girl died 5 months after HSCT due to disseminated adenovirus infection.

Zygomycosis in the immunocompromised patient: a case report.

Zygomycosis is a highly aggressive infection observed in immunocompromised patients, such as those with haematological malignancies. The sites most frequently involved are the sinuses and the lungs. New diagnostic tools and new antifungal treatments are essential in order to diagnose early and treat efficiently infections due to moulds. We report a case of sinusitis due to Absidia corymbifera occurring during chemotherapy-induced bone marrow aplasia in a patient with acute leukaemia. The sinusitis was successfully treated with AmBisome, and surgical debridement.

[Pulmonary mucormycosis in a multiple-trauma patient]. / Mucormycose pulmonaire chez un patient polytraumatisé.

Mucormycosis are opportunist infections occurring usually among predisposed patients. We report a case of an 18-year-old male with a severe thoracic trauma who developed an Absidia infection on his contused pulmonary parenchyma, without presenting the usual risk factors (diabetes mellitus, immunodeficiency). The early diagnosis using bronchoscopy has probably improved the outcome by allowing a faster treatment. After 18-months, the infectious process resolved thanks to a combination of a medical treatment composed of high-dose amphotericin B lipid formulation, itraconazole and a complementary surgical treatment.

[Abdominal zygomycosis in a bitch due to Absidia corymbifera]. / Cigomicosis abdominal en una perra causada por Absidia corymbifera.

We report a case of abdominal zygomicosis in a Doberman bitch. Clinical signs consisted of urinary incontinence and hard abdominal masses detected by palpation. The masses were surgically removed by exploratory laparatomy and had a tumoral-like appearance. A granulomatous reaction containing coarse and non septate hyphae was the main histological finding. Direct microscopic examination revealed the presence of fungal structures. On Sabouraud honey agar the fungus developed fluffy, greyish white colonies that were identified as Absidia corymbifera on the basis of their macro and microscopic morphology.

Fatal course of pulmonary Absidia sp. infection in a 4-year-old girl undergoing treatment for acute lymphoblastic leukemia.

Absidia sp. is a rare etiologic agent responsible for infectious complications in immunosuppressed patients. The authors describe a 4-year-old girl with acute lymphoblastic leukemia complicated with pleuropneumonia caused by an Absidia infection during the induction of remission. A review of the published reports in current literature is included for comparison. To the authors' knowledge only six cases of primary pulmonary absidiomycosis have been published. Despite its uncommon pulmonary presentation, mucormycosis should be considered in patients with an immunosuppressing illness and positive risk factors and when a pulmonary lesion is not responding to appropriate antibiotic therapy.