Pulmonary Zygomycosis 47-year-old male Type II diabetes mellitus for 13 years Developed diabetic neuropathy and end-stage renal disease Renal transplantation and immunosuppression One month post-transplant Fever, chills, pleuritic chest pain Chest x-ray = cavitary lesion in right upper lobe Sputum examinations negative for acid-fast bacilli ATT initiated Chakrabarti et al. J Clin Microbiol, 2010, 48(5): 1965-1969
Pulmonary Zygomycosis ATT failed Blood sugar 153 – 226 mg/dl Insulin therapy Fine needle aspirate of lesion Direct microscopy = no fungal elements Fungal cultures were negative at 4 weeks No improvement at 20 days Open-lung biopsy of lesion, no mass noted Chakrabarti et al. J Clin Microbiol, 2010, 48(5): 1965-1969
Pulmonary Zygomycosis Periodic acid-Schiff stain revealed acute inflammatory infiltrates and ribbon-like hyphae Chakrabarti et al. J Clin Microbiol, 2010, 48(5): 1965-1969
Pulmonary Zygomycosis Culture of the biopsy: Fast growing, floccose whit colony turning grayish Isolate identified as Rhizopus spp. Chakrabarti et al. J Clin Microbiol, 2010, 48(5): 1965-1969
Zygomycosis Epidemiology: Virulence factors and pathogenesis: Ubiquitous Usually – Rhizopus spp. Others: Mucor, Absidia, Rhizomucor, and Cunninghamella Virulence factors and pathogenesis: Tissue necrosis suggests tissue destructive enzymes Debilitated and immunocompromised especially diabetic ketoacidosis leukemias and lymphomas
Zygomycosis Clinical Manifestation: Route – inhalation Incubation - ??? Forms of infections: Rhinocerebral zygomycosis – oropharyngeal, periorbital paranasal sinus eye, brain Risk factor = metabolic acidosis Primary cutaneous zygomycosis (contaminated bandages) Disseminated – fulminant and fatal, very poor prognosis Cutaneous zygomycosis
Zygomycosis – Clinical Manifestations
Zygomycosis – Clinical Manifestations
Zygomycosis – Clinical Manifestations
Zygomycosis – Lab Diagnosis Laboratory Diagnosis: Monomorphic ,true mould In tissue: Try to get tissue for direct preps!! Aseptate hyphae that branch at RIGHT angles, rare septations are possible (may see sporangial fruiting bodies) In culture: Several etiologies are differentiated by sporangia Rhizopus spp.- Aseptate hyphae; sporangiophore arises from rhizoids, huge sporangia (100-300 um), filled with sporangiospores.
Rhizopus from a colony
Zygomycosis
Zygomycosis
Zygomycosis
Zygomycosis - Treatment Invasive disease is very difficult to treat/control Amphotericin B … plus supplement abx Surgical debridement Immune reconstitution Posiconazole appears to be active against most species
Pulmonary Zygomycosis For our patient: Liposomal Amphotericin B was administered Striking improvement both clinical and radiological No relapse at 5 months Classical presentation of a susceptible diabetic host Localized, primary pulmonary zygomycosis Chakrabarti et al. J Clin Microbiol, 2010, 48(5): 1965-1969