Pulmonary mucormycosis

Dr. Md. Shafiqul Islam Dewan

Resident (Pulmonology)
Dhaka Medical College Hospital
Mucormycosis
 Mucormycosis (previously called zygomycosis)
is opportunistic fungal infection caused by molds
in the order Mucorales.
 Rhizopus and Mucor are the most common
fungus in this order causes mucormycosis.
 It most commonly affects the sinuses or the lungs
after inhaling fungal spores from the air.
 It can also occur on the skin after a cut, burn, or
other type of skin injury.
Transmission

 Transmission occurs through inhalation,

inoculation or ingestion of spores from the
environment.

 There is no human to human transmission.

Pathogenesis
 Mucormycosis is angioinvasive, resulting in
thrombosis, infarction, and tissue necrosis, with
risk for dissemination to other sites.

 After fungal spores access to the host, mononuclear

and polymorphonuclear phagocytes normally serve
as a primary host defense against invasion.

 Hyperglycemia and acidosis in people with poorly

controlled diabetes impair phagocyte function.
Pathogenesis

 Systemic acidosis increases free iron by

decreasing iron binding to transferrin.

 Growth of pathogenic Mucorales is enhanced by

free iron.
Types of mucormycosis
 Rhinocerebral (sinus and brain) Mucormycosis

 Pulmonary (lung) Mucormycosis

 Gastrointestinal Mucormycosis

 Cutaneous (skin) Mucormycosis

 Disseminated mucormycosis
Rhinocerebral mucormycosis 
 The most common form in patients with diabetes and with
renal transplants. 
 It also occurs in neutropenic cancer patients and
hematopoietic stem cell transplant or solid organ transplant
recipients.
 Symptoms may include unilateral facial swelling,
headaches, nasal or sinus congestion or pain,
serosanguinous nasal discharge, and fever.
 As the infection spreads, ptosis, proptosis, loss of
extraocular muscle function, and vision disturbance
may occur.
 Necrotic black lesions on the hard palate or nasal turbinate
and drainage of black pus from eyes are useful diagnostic
signs.
Cutaneous mucormycosis
 May be primary or secondary.
 Primary infection is usually caused by direct inoculation
of the fungus into disrupted skin and is most often seen in
patients with burns or other forms of local skin trauma,
and can occur in patients who are not immunosuppressed.
 Primary infection produces an acute inflammatory
response with pus, abscess formation, tissue swelling, and
necrosis. The lesions may appear red and indurated and
often progress to black eschars.
 Secondary cutaneous infection is generally seen when
the pathogen spreads hematogenously; lesions typically
begin as an erythematous, indurated, and painful cellulitis
and then progress to an ulcer covered with a black eschar.
Gastrointestinal mucormycosis
 Less common than the other clinical forms and is believed to
result from ingestion of the organism.
 It typically occurs in malnourished patients or premature
infants.
 The stomach, colon, and ileum are most commonly affected.
 Non-specific abdominal pain and distension, nausea, and
vomiting are the most common symptoms, and
gastrointestinal bleeding can occur.
 It is the most common form of mucormycosis among
neonates and is challenging to diagnose partly because of its
clinical resemblance to necrotizing enterocolitis, a far more
common disease.
Disseminated mucormycosis

 may follow any of the forms of mucormycosis

but is usually seen in neutropenic patients with a
pulmonary infection.

 The most common site of spread is the brain, but

the spleen, heart, skin, and other organs can also
be affected.
Pulmonary Mucormycosis
 Pulmonary mucormycosis generally occurs in
patients with hematologic malignancy or
profound neutropenia.

 The symptoms are non-specific and include

fever, cough, chest pain, and dyspnea.

 Angioinvasion results in tissue necrosis, which

may ultimately lead to cavitation and/or
hemoptysis.
Risk factor for pulmonary
mucormycosis
 Neutropenia
 Uncontrolled Diabetes
 Solid organ or allogeneic stem cell transplantation
 Prolonged high-dose glucocorticoid therapy
 Leukaemia and other haematological
malignancies
 Cytotoxic chemotherapy
 Chronic Lung disease
Clinical manifestations

 Pulmonary mucormycosis is present with_

 Fever
 Cough,
 Dyspnea,
 Pleuritic chest pain and
 Haemoptysis.
Investigation
 Imaging:
 Chest X-ray PA view
 CT scan of chest
 Finding: Nodule, mass lesion, consolidation,
cavitary lesion and ground-glass opacities.
 Both the halo sign and the reversed halo sign
may be seen but the reversed halo appears to
be more common in Mucormycosis.
Investigation

 Microscopic examination: sputum and

BAL specimens
 may show the characteristic broad 10-to 20-μm,
ribbon-like, irregularly branching hyphae.

 Culture: Sputum or tissue

 Bronchoscopy
 findings include luminal narrowing or obstruction
with pseudomembranes and necrosis
Complication

 Life-threatening haemoptysis due to vascular

invasion by the fungus.

 Disseminate or expand locally to involve

contiguous structures, including the mediastinum
and chest wall.

 Uncommon: bronchopleural, bronchocutaneous

and bronchoarterial fistulas.
Treatment
 Specific treatment
 Liposomal amphotericin B (LAmB) treatment of choice
 LAmB is typically initiated at a dosage of 5 mg/kg/day
but has been increased to 10 to 15 mg/kg/day in severe
infections that fail to respond.

 Azoles: posaconazole and isavuconazole.

 As step-down therapy or
 As a component of salvage regimens in patients
refractory to or intolerant of AmB.
Prognosis

 The overall prognosis depends on several factors,

including the rapidity of diagnosis and treatment,
the site of infection, and the patient’s underlying
conditions and degree of immunosuppression.

 The overall mortality rate is approximately

50%,  although early identification and treatment
can lead to better outcomes.