Mucormycosis (Zygomycosis) Clinical Presentation

Updated: Sep 10, 2018
  • Author: Philip J McDonald, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Presentation

History and Physical Examination

Based on anatomic localization, mucormycosis can be classified as 1 of 6 forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon presentations. [11] 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 congestion, which progresses to black discharge. Initially, mucormycosis may mimic bacterial sinusitis. [21, 22]

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 a reduced level of consciousness. Most patients with rhinocerebral disease have diabetes (especially with ketoacidosis) or have malignancies with associated neutropenia and may be receiving broad-spectrum antibiotics.

An immunocompetent man who sustained a high-pressu 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.

Orbital swelling and facial cellulitis are progressive. Necrotic eschars with black purulent discharge can be noted in the nasal cavity, on the hard palate, or on the face. Although these lesions suggest 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 level of consciousness 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 hematologic malignancies and a history of neutropenia. [23] 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. Occasionally, chest wall cellulitis can occur adjacent to the underlying parenchymal disease, given the ability of this infection to cross tissue planes.

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 vascular 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. [5, 6] Rare cases have occurred at catheter sites or insulin or illicit drug 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 [24] or obstruction [25] may occur. Some patients have tenderness to palpation or a mass. Rupture may lead to signs of peritonitis.

Disseminated disease

Other disseminated forms of mucormycosis may involve the kidneys, bones, heart, and other locations, with symptoms attributed to these organ systems. Peritonitis in the setting of continuous ambulatory peritoneal dialysis has also been described. [26]

Other forms including central nervous system

Central nervous system (CNS) disease manifests as headache, decreasing level of 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.