Introduction Zygomycetes are ubiquitous fungi that can cause invasive disease in susceptible hosts, with a wide spectrum of clinical presentations and cause very high mortality. Although aspergillosis and candidiasis are still the most common invasive mycoses in immuno-compromised hosts, but recent epidemiology suggest that the incidence of Zygomycosis has risen significantly over the past decade. We describe 2 cases of zygomycosis who unfortunately had fatal outcome despite an aggressive therapy. Case Summary 1 67-year-old man was brought to casualty, found collapsed at home. His admission tests revealed that he was in diabetic ketoacidosis (BM >60 and PH 6.9), although he was not a known diabetic. With an aggressive management of his metabolic derangement, he gradually became conscious and complained of bilateral frontal headache and complete blindness. On examination he had bilateral swollen eyes with chemosis & tenderness, complete ophthalmoplegia, blindness with no perception of light and normal optic discs. CT angiogram revealed normal brain parenchyma and cortical veins with mildly thickened mucosa of maxillary sinuses without bony erosion. CSF examination showed WCC 348 with 60% polymorphs, protein 0.7 gm, glucose 9.1(serum 18) and negative microbiology. ENT surgeons were reluctant to intervene at this stage, as there was no radiological evidence suggesting an invasive pathology. Despite an aggressive management with broad-spectrum antibiotics plus AmBisome, he deteriorated rapidly and died. However a post-mortem examination confirmed the diagnosis of rhino-sino-cerebral mucormycosis. Case Summary 2 44-year-old man with Acute Lymphoblastic Leukaemia had prolonged neutropenia following first phase of induction chemotherapy. On day 22 post-chemo, he developed acute painful swelling of left side of face associated with headache and dizziness. He was febrile and examination of his mouth revealed a well-demarcated necrotic ulcer with slough over the left side his hard palate. CT scan revealed marked soft tissue opacification without bony erosion of the left maxillary antrum and ethmoidal air cells, with associated pre-septal cellulitis extending down to neck. Antral biopsy revealed inflamed mucosa with necrotic slough containing large fungal hyphae and cultures grew Rhizopus arrhizus. He responded well to AmBisome plus Voriconazole combination therapy and also, he underwent repeated debridements and anterostomy after some persuation. Unfortunately he succumbed to unrelated infection later with multi-resistant Psedomonas bacteraemia. Discussion A recent study which reviewed 929 cases of zygomycosis in the Englishlanguage literature since 1885, has shown survival of 3% for untreated cases, 61% for cases treated with amphotericin B, 57% for cases treated with surgery alone, and 70% for cases treated with antifungal therapy plus surgery. This clearly reinforces the role of surgical debridement in addition to antifungal therapy in the management of these complex infections.
Full conference title:
Federation of Infection Societies conference
- FIS (2007)