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Zygomycosis Workup

  • Author: Jose A Vazquez, MD, FACP, FIDSA; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
 
Updated: Aug 12, 2015
 

Laboratory Studies

Unfortunately, findings from laboratory studies are nonspecific for zygomycosis.[9, 15] Diagnosis requires a high index of suspicion, a host with appropriate risk factors, and evidence of tissue invasion with the characteristic appearance of broad nonseptate hyphae with right-angle branches.[12, 14] No serologic tests are available, and blood cultures are of no benefit.[1]

Rhinocerebral mucormycosis

Discharge scrapings may be examined with potassium hydroxide (KOH) to reveal broad irregularly shaped hyphae with right-angle branching (as seen in the image below).

Material from the periorbital tissue of a woman wi Material from the periorbital tissue of a woman with poorly controlled diabetes mellitus with facial and periorbital swelling due to zygomycosis is stained with periodic acid-Schiff stain (X 560). The material demonstrates the classic appearance of irregularly shaped broad hyphae with right-angle branching (arrow).

Fungal stains of biopsy material obtained from affected tissue remains the mainstay for a definitive diagnosis.

Fungal culture of biopsy tissue also may be helpful, but results frequently are negative despite positive histopathology. In fact, fungal culture results are only positive in 15-25% of cases.

Pulmonary mucormycosis

Sputum smear and cultures are rarely helpful.

Lung tissue biopsy is generally needed for diagnosis.

Gastrointestinal mucormycosis

Most cases of gastrointestinal infection are diagnosed at surgery or postmortem.

Fungal stains and cultures of biopsy material are needed for definitive diagnosis.

Cutaneous mucormycosis

Diagnosis of this type requires fungal stains and cultures of a skin biopsy.

Disseminated mucormycosis

Blood cultures are of no benefit.

Fungal stains and cultures of affected tissue and histopathologic identification of the fungus are needed.

Brain biopsy may be helpful.

Cerebrospinal fluid analysis is generally nonspecific, even in the presence of brain involvement.

Cerebrospinal fluid abnormalities include slightly increased pressure, modest pleocytosis with predominant polymorphonuclear cells, and slightly elevated protein levels. Hypoglycorrhachia is unusual. Erythrocytosis is occasionally observed. Fungal stains and culture results are rarely positive.

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Imaging Studies

Rhinocerebral mucormycosis

Plain radiographs of sinuses and orbits may demonstrate sinus mucosal thickening, with or without air-fluid levels, but this is nonspecific.

CT scans with contrast or MRI may demonstrate erosion or destruction of bone or sinuses and delineate the extent of disease (as seen in the image below).

A CT scan of the head of a patient with zygomycosi A CT scan of the head of a patient with zygomycosis shows involvement of the paranasal sinuses and periorbital soft tissues.

Pulmonary mucormycosis

Chest radiographs may demonstrate single or multiple large masslike infiltrates, pulmonary nodules, and cavitary lesions. These lesions, however, are indistinguishable from those caused by aspergillosis.

CT scan with contrast may help delineate the extent of disease.

Gastrointestinal mucormycosis

Abdominal radiographs may demonstrate air under the diaphragm in patients with perforation.

Barium studies of the upper GI tract or colon may demonstrate a filling defect or a masslike effect that suggests zygomycosis.

Disseminated mucormycosis

CT scan of the chest and head may demonstrate invasive disease and delineate the extent of disease.

CT scan of the abdomen and pelvis may demonstrate lesions in the liver, spleen, kidney, pancreas, stomach, and omentum.

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Procedures

Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy provides adequate tissue to diagnose pulmonary mucormycosis.

CT-guided percutaneous lung biopsy may also be beneficial.[17]

Open lung biopsy may be required if bronchoscopy findings are negative.

Endoscopy provides direct examination of the esophagus and stomach, the most commonly affected organs in patients with gastrointestinal mucormycosis.

Brain biopsy may be required to establish a diagnosis.

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Histologic Findings

Fixed tissue can be stained with hematoxylin and eosin (H&E). Fungal hyphae may be demonstrated with Grocott methenamine-silver stain or periodic acid-Schiff (PAS) staining. The typical appearance demonstrates the fungus as broad, nonseptate hyphae with acute right-angle branching.

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Contributor Information and Disclosures
Author

Jose A Vazquez, MD, FACP, FIDSA Professor of Medicine, Section Chief, Division of Infectious Diseases, Department of Medicine, Georgia Regents University

Jose A Vazquez, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Mycological Society of the Americas, International Society for Human and Animal Mycology, HIV Medicine Association, Michigan Infectious Disease Society, National Foundation for Infectious Diseases, Mycological Society of America, Immunocompromised Host Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Allergan; Astellas; Pfizer<br/>Received research grant from: Merck; Astellas<br/>Received grant/research funds from Merck for independent contractor; Received honoraria from Forest for speaking and teaching; Received honoraria from Astellas for speaking and teaching; Received consulting fee from Cidara for consulting.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Additional Contributors

Gary L Gorby, MD Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center

Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences

Disclosure: Nothing to disclose.

References
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A 45-year-old woman with poorly controlled diabetes mellitus with facial and periorbital swelling due to zygomycosis. She was unable to open her right eye upon admission.
Material from the periorbital tissue of a woman with poorly controlled diabetes mellitus with facial and periorbital swelling due to zygomycosis is stained with periodic acid-Schiff stain (X 560). The material demonstrates the classic appearance of irregularly shaped broad hyphae with right-angle branching (arrow).
A CT scan of the head of a patient with zygomycosis shows involvement of the paranasal sinuses and periorbital soft tissues.
A 60-year-old woman with diabetes mellitus and 5 days post operative from resection of a benign pituitary tumor. The lesion developed over the surgical scar. Biopsy of lesion demonstrated invasive cutaneous mucormycosis.
 
 
 
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