Mucormycosis Clinical Presentation

  • Author: Nancy F Crum-Cianflone; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 8, 2011
 

History and Physical Examination

Manifestations of mucormycosis depend on the location of involvement.

Rhinocerebral disease

Rhinocerebral disease may manifest as unilateral, retro-orbital headache, facial pain, numbness, fever, hyposmia, and nasal stuffiness, which progresses to black discharge. Initially, mucormycosis may mimic sinusitis.[8]

Late symptoms that indicate invasion of the orbital nerves and vessels include diplopia and visual loss (see the following image). These late symptoms indicate a poor prognosis and are usually followed by reduced consciousness. Most patients with rhinocerebral disease have diabetes (especially with ketoacidosis) or have malignancies in combination with neutropenia and who may be receiving broad-spectrum antibiotics.

An immunocompetent man who sustained a high-pressuAn immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. A surgical field of this patient is shown. Excision of the right orbit, maxillary antrum, nasal cavity, sphenoid sinus, and infratemporal fossa has taken place. The tissue was infarcted. (Courtesy of A. Allworth, MD, Brisbane, Australia.)

Orbital swelling and facial cellulitis are progressive. Black pus discharges from the necrotic palatine or nasal eschars. Necrotic eschars can be noted in the nasal cavity, on the hard palate, or as facial lesions; although these lesions are suggestive of mucormycosis, their absence does not exclude the possibility of this disease.

Proptosis, ptosis, chemosis, and ophthalmoplegias indicate retro-orbital extension. Cranial nerves V and VII are the most commonly affected. Loss of vision can occur with retinal artery thrombosis.

A reduced conscious state denotes brain involvement.

Pulmonary disease

Pulmonary mucormycosis manifests nonspecifically as fever, dyspnea, and cough. Hemoptysis may occur in the presence of necrosis. Most patients with pulmonary disease have malignancies and a history of neutropenia. Pulmonary disease frequently occurs with concurrent sinus involvement.

The signs of pulmonary disease are nonspecific. Fevers are often noted. The lung examination may reveal decreased breath sounds and rales.

Cutaneous disease

Cutaneous disease manifests as cellulitis, which progresses to dermal necrosis and black eschar formation. The progressive black necrotic lesion of cutaneous mucormycosis reflects the vessel invasion characteristic of all forms of the disease.

Patients with skin disease may have had previous trauma or have been exposed to contaminated medical equipment, such as bandages. Rare cases have occurred at catheter sites or insulin or drug-use injection sites.

Gastrointestinal

Gastrointestinal (GI) mucormycosis usually affects severely malnourished individuals. Some case reports have described GI mucormycosis in transplant patients (eg, renal transplant). This infection may occur throughout the GI tract but most commonly affects the stomach, ileum, and colon. Again, the presentation is nonspecific, with abdominal pain, distention, nausea, and vomiting. Hematochezia may occur. Some patients have tenderness to palpation or a mass; rupture may lead to signs of peritonitis.

Central nervous system

Central nervous system (CNS) disease manifests as headache, decreasing consciousness, and focal neurologic symptoms/signs, including cranial nerve deficits. Patients with CNS involvement may have a history of open head trauma, intravenous drug use, or malignancy.

Disseminated disease

Other disseminated forms of mucormycosis may involve the kidneys, bones, and heart, with symptoms attributed to these organ systems. Peritonitis in the setting of continuous ambulatory peritoneal dialysis has also been described.[9]

Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Nancy F Crum-Cianflone  MD, MPH, Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Naval Medical Center at San Diego

Nancy F Crum-Cianflone is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Ron W Pelton, MD, PhD  Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

Kimberly G Yen, MD  Assistant Professor of Ophthalmology, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine

Kimberly G Yen, MD is a member of the following medical societies: Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Michael T Yen, MD  Associate Professor of Ophthalmology, Department of Ophthalmology, Division of Ophthalmic Plastic, Lacrimal, and Orbital Surgery, Cullen Eye Institute, Baylor College of Medicine

Michael T Yen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Maria D Mileno, MD  Associate Professor of Medicine, Division of Infectious Diseases, The Warren Alpert Medical School of Brown University

Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, University of Oklahoma College of Medicine

Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

  1. Kontoyiannis DP, Lewis RE. Agents of mucormycosis and Entomophthoramycosis. In: Mandell GL, Bennett GE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Churchill Livingstone; 2010:3257-69.

  2. Mohindra S, Mohindra S, Gupta R, et al. Rhinocerebral mucormycosis: the disease spectrum in 27 patients. Mycoses. Jul 2007;50(4):290-6. [Medline].

  3. Andresen D, Donaldson A, Choo L, et al. Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka. Lancet. Mar 5-11 2005;365(9462):876-8. [Medline].

  4. Kontoyiannis DP, Wessel VC, Bodey GP, et al. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis. Jun 2000;30(6):851-6. [Medline].

  5. Kontoyiannis DP, Marr KA, Park BJ, et al. Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001-2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) Database. Clin Infect Dis. Apr 15 2010;50(8):1091-100. [Medline].

  6. Pagano L, Ricci P, Tonso A, et al. Mucormycosis in patients with haematological malignancies: a retrospective clinical study of 37 cases. GIMEMA Infection Program (Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto). Br J Haematol. Nov 1997;99(2):331-6. [Medline].

  7. Lee FY, Mossad SB, Adal KA. Pulmonary mucormycosis: the last 30 years. Arch Intern Med. Jun 28 1999;159(12):1301-9. [Medline].

  8. Szalai G, Fellegi V, Szabo Z, et al. Mucormycosis mimicks sinusitis in a diabetic adult. Ann N Y Acad Sci. Nov 2006;1084:520-30. [Medline].

  9. Polo JR, Luño J, Menarguez C, Gallego E, Robles R, Hernandez P. Peritoneal mucormycosis in a patient receiving continuous ambulatory peritoneal dialysis. Am J Kidney Dis. Mar 1989;13(3):237-9. [Medline].

  10. Gelston CD, Durairaj VD, Simoes EA. Rhino-orbital mucormycosis causing cavernous sinus and internal carotid thrombosis treated with posaconazole. Arch Ophthalmol. Jun 2007;125(6):848-9. [Medline].

  11. Spellberg B, Walsh TJ, Kontoyiannis DP, Edwards J Jr, Ibrahim AS. Recent advances in the management of mucormycosis: from bench to bedside. Clin Infect Dis. Jun 15 2009;48(12):1743-51. [Medline]. [Full Text].

  12. Sedlacek M, Cotter JG, Suriawinata AA, et al. Mucormycosis peritonitis: more than 2 years of disease-free follow-up after posaconazole salvage therapy after failure of liposomal amphotericin B. Am J Kidney Dis. Feb 2008;51(2):302-6. [Medline].

  13. Rickerts V, Atta J, Herrmann S, et al. Successful treatment of disseminated mucormycosis with a combination of liposomal amphotericin B and posaconazole in a patient with acute myeloid leukaemia. Mycoses. 2006;49 Suppl 1:27-30. [Medline].

  14. Ashkenazi-Hoffnung L, Bilavsky E, Avitzur Y, Amir J. Successful treatment of cutaneous zygomycosis with intravenous amphotericin B followed by oral posaconazole in a multivisceral transplant recipient. Transplantation. Nov 27 2010;90(10):1133-5. [Medline].

  15. Yoon YK, Kim MJ, Chung YG, Shin IY. Successful treatment of a case with rhino-orbital-cerebral mucormycosis by the combination of neurosurgical intervention and the sequential use of amphotericin B and posaconazole. J Korean Neurosurg Soc. Jan 2010;47(1):74-7. [Medline]. [Full Text].

  16. van Well GT, van Groeningen I, Debets-Ossenkopp YJ, et al. Zygomycete infection following voriconazole prophylaxis. Lancet Infect Dis. Sep 2005;5(9):594. [Medline].

  17. Trifilio SM, Bennett CL, Yarnold PR, et al. Breakthrough zygomycosis after voriconazole administration among patients with hematologic malignancies who receive hematopoietic stem-cell transplants or intensive chemotherapy. Bone Marrow Transplant. Apr 2007;39(7):425-9. [Medline].

  18. Alastruey-Izquierdo A, Castelli MV, et al. In vitro activity of antifungals against Zygomycetes. Clin Microbiol Infect. Oct 2009;15 Suppl 5:71-6. [Medline].

  19. Spellberg B, Ibrahim AS. Recent advances in the treatment of mucormycosis. Curr Infect Dis Rep. Nov 2010;12(6):423-9. [Medline]. [Full Text].

  20. Ibrahim AS, Gebremariam T, Fu Y, Edwards JE Jr, Spellberg B. Combination echinocandin-polyene treatment of murine mucormycosis. Antimicrob Agents Chemother. Apr 2008;52(4):1556-8. [Medline]. [Full Text].

  21. Ogawa T, Takezawa K, Tojima I, et al. Successful treatment of rhino-orbital mucormycosis by a new combination therapy with liposomal amphotericin B and micafungin. Auris Nasus Larynx. May 16 2011;[Medline].

  22. Keating GM. Posaconazole. Drugs. 2005;65(11):1553-67; discussion 1568-9. [Medline].

  23. Greenberg RN, Mullane K, van Burik JA, et al. Posaconazole as salvage therapy for zygomycosis. Antimicrob Agents Chemother. Jan 2006;50(1):126-33. [Medline].

 
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Postmortem photograph of a woman with diabetes and left rhinocerebral mucormycosis complicating ketoacidosis. Rhizopus oryzae was the causative organism. Note the orbital and facial cellulitis and the black nasal discharge. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
The right eye of an immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. Note the proptosis. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
The right eye of an immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. Chemosis is shown in this photograph. Internal and external ophthalmoplegia, no light perception, and afferent pupil defect were present, which is consistent with orbital apex syndrome. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
An immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. A surgical field of this patient is shown. Excision of the right orbit, maxillary antrum, nasal cavity, sphenoid sinus, and infratemporal fossa has taken place. The tissue was infarcted. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
An immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. Picture of the patient after successful treatment with repeated surgical debridement and high-dose liposomal amphotericin B. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
Histologic findings from an immunocompetent man who sustained a high-pressure water jet injury, resulting in rhinocerebral mucormycosis. Traumatic inoculation of Apophysomyces elegans was the pathogenetic mechanism. Findings show the typical Mucorales hyphae on Grocott methenamine-silver staining. The hyphae are the dark structures with budlike, right-angle hyphae. (Courtesy of A. Allworth, MD, Brisbane, Australia.)
Chest computed tomography (CT) scan showing pulmonary mucormycosis with left basal consolidation and widespread nodules due to Rhizopus oryzae infection. The patient was receiving cytotoxic chemotherapy for myelodysplastic syndrome and had iron overload from numerous blood transfusions.
Chest computed tomography (CT) scan showing pulmonary mucormycosis with left basal consolidation and widespread nodules due to Rhizopus oryzae infection. The patient was receiving cytotoxic chemotherapy for myelodysplastic syndrome and had iron overload from numerous blood transfusions. This CT scan of the patient shows resolution of pulmonary mucormycosis after 5 months of antifungal treatment.
 
 
 
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