1. 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):

2. 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):

3. Pulmonary Zygomycosis
Periodic acid-Schiff stain revealed acute inflammatory infiltrates and ribbon-like hyphae
Chakrabarti et al. J Clin Microbiol, 2010, 48(5):

4. 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):

5. 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

6. 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

7. Zygomycosis – Clinical Manifestations

8. Zygomycosis – Clinical Manifestations

9. Zygomycosis – Clinical Manifestations

10. 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 ( um), filled with sporangiospores.

11. Rhizopus from a colony

12. Zygomycosis

13. Zygomycosis

14. Zygomycosis

15. 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

16. 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):