Background
This fungal infection is an opportunistic infection. One of the more common presentations is an infection in the nasal sinuses in patients with a diabetic ketoacidosis or diabetic coma. These organisms have a propensity to invade blood vessels causing thrombosis and infarction of the surrounding tissues.
OUTLINE
DISEASE ASSOCIATIONS CHARACTERIZATION Diabetes mellitus GOUT
Am J Dermatopathol. 2006 Aug;28(4):327-30 Abstract quote
Cutaneous zygomycosis is being increasingly recognized as a serious and life-threatening infection in debilitated and immunosuppressed patients, including transplant patients. The organisms are morphologically distinct but difficult to grow in cultures from clinical samples.
We report a case of cutaneous zygomycosis in a neonatal multi-visceral organ transplant patient, with subcutaneous panniculitis accompanied by extensive local acicular uric acid crystal deposition. Although the patient's serum uric acid was subsequently found to be in the normal range, transient hyperuricemia could not be excluded. Because we use a microwave-based processing system avoiding aqueous solutions, the crystals were maintained in the tissue sections and were shown by various methods to consist of monosodium urate. Early diagnosis combined with extensive debridement and prompt antifungal therapy resulted in a successful outcome.
We have coined the term "urate panniculitis" to describe this phenomenon.Hematologic malignancies Malnutrition Immunocompromised states HIV J Am Acad Dermatol 1994;30:904-908
Does not increase the risk of infection unless the patient has a history of IV drug abuse
LABORATORY/
RADIOLOGICCHARACTERIZATION CULTURES
Increased culture recovery of zygomycetes under physiologic temperature conditions.Department of Infectious Diseases, Infection Control and Employee Health, University of Houston College of Pharmacy, Houston, TX 77030, USA.
Am J Clin Pathol. 2007 Feb;127(2):208-12 Abstract quote
Poor recovery of Zygomycetes hyphae from tissue specimens may result from failure of current culture methods to mimic physiologic conditions found in hyphae-laden infected tissue.
We describe the use of an in vitro model simulating Zygomycetes growth under necrotic or hypoxic tissue conditions. We preconditioned hyphae of clinical Zygomycetes isolates in flasks under anaerobic conditions using Ana-Packs (Becton Dickinson Microbiology Systems, Sparks, MD) at 37 degrees C for 48 hours, thus simulating in vivo growth in an infracted hypoxic lesion, and compared the recovery of paired inocula at 37 degrees C and 25 degrees C. Incubation of stock culture isolates at 37 degrees C resulted in significantly better culture recovery (about 10-fold) when compared with incubation at 25 degrees C (P < .0001). In addition, we similarly evaluated 25, 291 consecutive clinical specimens.
Among 41 specimens, the yield of Zygomycetes cultures incubated at 37 degrees C (23/41 [56%]) was significantly higher than that incubated at 25 degrees C (9/41 [22%]; P = .0001). Overall, we found that culture recovery was significantly (254%) enhanced at 37 degrees C.
HISTOLOGICAL TYPES CHARACTERIZATION General Arch Pathol Lab Med 125:375–378, 2001
The inflammatory responses were predominantly neutrophilic (50%), predominantly granulomatous (5%), pyogranulomatous (25%), or absent (20%)
Invasive disease was characterized by prominent infarcts (94%), angioinvasion (100%), and prominent perineural invasion (90%) in biopsies that contained nerves for evaluation
At least rare hyphal septa were always seen (100%), and most branches (95%) varied from 45° to 90°
Perineural invasion is a common finding in invasive zygomycosis, as are angioinvasion and infarcts
Prior to excluding the presence of these fungi in biopsies suspected to contain zygomycetes, the perineural space should be carefully examinedVARIANTS NECROTIZING FASCIITIS
Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases.1Department of Histopathology, Post-graduate Institute of Medical Education and Research, Chandigarh, India.
Mod Pathol. 2006 Sep;19(9):1221-6. Abstract quote
Necrotizing fasciitis is most often associated with bacterial infections. Zygomycosis is an uncommon infection causing necrotizing fasciitis.
We report 18 such cases of zygomycotic necrotizing fasciitis, of these, 15 were immunocompetent. Of the eight cases cultured, five were positive for Apophysomyces elegans. A retrospective case review conducted at a tertiary referral center, from 1998 to 2004, 18 cases of fungal necrotizing fasciitis were diagnosed based on histomorphology of fungal organisms; and in few of the cases diagnosis was supported by mycologic culture reports. Of the total of 18 cases, culture report was available in eight cases, and out of which five of them grew A. elegans. Fifteen patients were immunocompetent. Clinical presentation, mycologic findings and histopathologic results were evaluated.
A review of the literature pertaining to A. elegans infection was also done. Histopathologic examination showed broad, predominantly aseptate and occasional pauciseptate, thin-walled fungal hyphae with occasional angioinvasion. To the best of our knowledge, this is the first largest series of zygomycotic necrotizing fasciitis from India.
Herein, we present data on 18 cases of necrotizing fasciitis assosiated with zygomycosis. Most of the cases in our series were immunocompetent. Nonsuppurative necrosis with presence of typical fungal profiles was important histologic feature.
Zygomycosis must be considered in the differential diagnosis not only in immunocompromised patients but also in the absence of any underlying disorders.SKIN Large necrotic areas with suppuration involving the dermis and subcutaneous tissue
Hyphae common within the vessels causing thrombosis and infarction
SPECIAL STAINS/
IMMUNOPEROXIDASE/
OTHERCHARACTERIZATION Special stains PAS positive
GMS weakly positive
Clin Infect Dis 1992;14:126S-129S
J Am Acad Dermatol 1994;30:904-908
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Last Updated February 12, 2007
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