Surgical resection and liposomal amphotericin B to treat cavitary pulmonary zygomycosis in a patient with diabetes.

We describe a 24-year-old man with type 1 diabetes mellitus and a cavitary lesion in the right upper lobe, caused by a zygomycete. Surgical resection plus liposomal amphotericin B therapy was successful. We discuss predisposing condition, clinical findings, diagnosis, and treatment of pulmonary zygomycosis.

[Zygomycosis].

Zygomycosis is an invasive fungal infection with extremely high mortality caused by filamentous fungi which belong to Class Zygomycetes (Rhizopus spp., Mucor spp., Cunninghamella spp., etc). Despite of the similarities of the ecological characteristics and of the patients' backgrounds, zygomycosis is much rarer than invasive aspergillosis. In addition to well known immunosuppressive risk factors (hematological malignancy, hematopoietic stem cell or solid organ transplant, prolonged neutropenia, corticosteroid, etc), diabetic ketoacidosis, iron overload, and administration of deferoxamine are specific factors predisposing zygomycosis. Rhinocerebral, pulmonary and disseminated disease is characteristic forms. The mainstay of the treatment is surgical resection, reversal of immunosuppressive factors, and administration of high-dose amphotericin B or its liposomal formulation. Because of the difficulty of culture detection and the absence of reliable serological diagnostic methods, premortem diagnosis and no delaying of effective treatment remain a challenge to physicians.

Rhinocerebral zygomycosis: an increasingly frequent challenge: update and favorable outcomes in two cases.

Zygomycosis or mucormycosis is an increasingly frequent life-threatening infection caused by opportunistic fungal organisms of the class Zygomycetes. The pathognomonic feature is the presence of invasive aseptate mycelia that are larger than other filamentous fungi with the hyphae exhibiting right angle and haphazard branching. Usually classified as rhinocerebral, disseminated, and cutaneous types, this classification serves as important predictor of pathogenesis and outcome. These occur mostly in immunosuppressed patients including individuals with diabetes (43% exhibit the rhino-cerebral form) and patients with organ transplants and hematologic malignancies. Without early aggressive treatment, the disease follows a dismal and fatal course. The prognosis has not shown any appreciable change in the past 40 years with a stagnant mortality rate of 44%. We present 2 cases of rhinocerebral zygomycosis (RCZ), in a 58-year-old male and a 63-year-old female; both were poorly controlled diabetic patients with maxillary lesions suggestive of osteomyelitis. The patients were leading a near normal life with minimal discomfort or signs and symptoms of underlying mycosis. Most of the health care professionals treating these patients often overlooked the disease or recommended inadequate therapy. Despite long delays and inadequate initial therapy these patients survived with little outward morbidity. The prognosis for this condition may therefore be considered less dire than previously thought.

[Rhino-orbital zygomycosis]. / Rino-orbitalna zigomikoza.

Zygomycosis is rare but highly invasive fungal infection, with high mortality rate. A 67 years old diabetic man was presented with rhino-ocular form of the disease. Fungal elements invaded the skin and subutaneous facial tissue, with involvement of the nose, paranasal sinuses and orbit. The portal of entry of fungus was through paranasal sinuses, after the tooth extraction. Various clinical manifestations were presented: headache, facial swelling, tenderness over the involved sinuses, unilateral orbital cellulitis with proptosis, facial and orbital pain, black nasal discharge, decreased visual acuity, blindness. Patient was treated surgically and by liposomal amphotericin B. He underwent maxillectomy, ethmoidectomy and sphenoidectomy and orbital exenteration because of the dissemination of the disease into the orbit. The specific diagnosis of the infection was established upon the microscopic demonstration of casual agent in the debridement tissue. Early diagnosis was important in this highly fatal disease. Aggressive surgical debridement, therapy with amphotericin B and correction of underlying metabolic acidosis must be performed. The successful medical therapy in this patient suggests that lipid formulation of amphotericin B should be given, because this antifungal agent performed the best control of the infection with the minimal adverse effects.

Zigomicosis rino-sinuso-orbital post-traumática / Post-traumatic rhino-sinus-orbital zygomycosis

Se describe un caso de zigomicosis rino-seno-orbital en un paciente sin antecedentes de inmunodeficiencia que presenta exolftalmia izquierda y lesiones infiltrativas edematosas en párpado inferior, nariz y región molar homolateral de rápida evolución. El hallazgo de abundantes hifas hialinas anchas, no tabicadas y tortuosas en biopsia cutánea de fistula intraorbitaria y en secreción nasal, junto a la obtención de cultivos puros de rhizopus oryzae, confirmaron el diagnóstico. La extracción del 2º molar superior izquierdo se interpretó como factor local de implantación traumática del agente etiológico y el reconocimiento de los síntomas clínicos iniciales fue crucial para el diagnóstico precoz. esta micosis no constituye un grave problema de salud, no obstante, en Tucumán debe tenerse presente su existencia