Mediastinal Mucormycosis: Case report,review of literature and treatment with continuous liposomal amphotericin B irrigation

Mediastinal mucormycosis is an uncommon but lethal infection associated with an 83% mortality. We describe a case of fatal Rhizopus microsporus mediastinitis despite three exploratory mediastinal surgeries and complementary systemic and mediastinal irrigation with liposomal amphotericin B. We further review the literature on surgical and antifungal management of mediastinal mucormycosis.     

Zygomycosis--a case report and overview of the disease in India

A case of zygomycosis caused by Rhizopus oryzae in a diabetic patient previously misdiagnosed as invasive pulmonary aspergillosis and an overview of the disease in India are presented. The case was diagnosed by direct microscopy, histopathologic examination and culture. Following surgical resection of pulmonary cavity under cover of amphotericin B administration, the patient recovered completely. Of 461 cases reported to-date, approximately 70% had been diagnosed at the Postgraduate Institute of Medical Education and Research, Chandigarh, in north India. This may be attributed to better awareness, expertise and infrastructural facilities for mycological diagnosis than to any particular regional preponderance of the disease. Rhino-orbito-cerebral manifestations were the most common feature of zygomycosis (269 cases), followed by cutaneous disease (66 cases), which is in conformity with the pattern prevalent worldwide. The etiologic agents encountered were Rhizopus oryzae, Apophysomyces elegans, Saksenaea vasiformis, Cunninghamella bertholletiae, Absidia corymbifera, Basidiobolus ranarum and Conidiobolus coronatus. In contrast to cases from the developed world where transplant recipients and patients with haematological malignancies seem to be most vulnerable to zygomycosis, the most common risk factor in India was uncontrolled diabetes mellitus. Amphotericin B was the mainstay of various treatment modalities employed. The relevance of a strong clinical suspicion and early diagnosis of zygomycosis for favourable prognosis can hardly be over-emphasised.     

Chronic rhinocerebral mucormycosis: a rare case report and review of the literature

Rhinocerebral mucormycosis is an invasive infection caused by filamentous fungi of the Mucoraceae family. The rhinocerebral form of the disease represents the most common form and has two distinct clinical entities. The common presentation consists of a rapidly progressive infection with high mortality rate, while the other presentation is that of a chronic infection with lower mortality. In the present paper we report a rare case of chronic rhinocerebral mucormycosis. An 85‐year‐old male with a 6‐month history of purulent and odorous nasal discharge, and sporadic episodes of epistaxis and anosmia, presented to the outpatient department of our clinic. Initial cultures were positive only for Pseudomonas aeruginosa. The patient was unresponsive to ciprofloxacin treatment, developing necrotic areas of the nasal septum suspicious for rhinocerebral mucormycosis. Admission to the ENT clinic followed, with histopathologic evaluation of the vomer bone confirming the diagnosis. The patient was treated with amphotericin B and was discharged 3 weeks later on oral posaconazole therapy. Chronic rhinocerebral mucormycosis may present with atypical symptoms or coinfection with another agent. A high degree of clinical suspicion is required for correct diagnosis and prompt initiation of appropriate treatment.     

Cancer cervix: Establishing an evidence-based strategy,an experience of a tertiary care centre in India

Carcinoma cervix is a common cancer among Indian women. Evidence based management is essential for best practice in treatment of carcinoma cervix for its effective control. The current imaging system like CT, MRI and PET CT scans have contributed in identifying the patients for optimal treatment and delivering treatment accurately. For stages IB2 to IV, concurrent chemoradiation is advocated with improvement in overall survival proven with randomized trials. Brachytherapy is an integral part in the radiation treatment. Imaged-guided brachytherapy using MRI is desirable, however less expensive imaging modalities such as CT and ultrasonography has been evaluated. In special situation such as for HIV positive patients and patients with neuroendocrine tumors have role of radiotherapy. For further improvement in control of cancer, it is required to integrate basic research to answer clinically relevant questions.     

Gynecological malignancies: epidemiological characteristics of the patients in a tertiary care hospital in India

Background: This cross-sectional observational study was undertaken to identify the epidemiologicalcharacteristics of patients with gynecological malignancies in India, in relation to gynecological cancer risk.Methods: In the gynecology out-patient clinic of a tertiary care hospital in Kolkata, India, the patients withsuggestive symptoms of gynecological malignancies were screened. One hundred thirteen patients withhistopathologically confirmed gynecological malignancies were interviewed. Results: More than two-thirds ofthe cases (69.0%) occurred in the age range of 35-64 years and the same proportion of patients was from ruralareas. Almost all the patients were “ever-married” (96.5%). More than half (54.9%) were illiterate/just literate.Nearly two-thirds (64.6%) were parity 3 or higher. Among the 18 patients with history of multiple sexual partnersof the husband, 94.4% (17) were suffering from cervical malignancy, along with all the 3 patients with historyof STD syndromes (sexually transmitted diseases) of their husbands. No one had given a history of condom useby her husband. Most of the patients (91.1%) used old / reused cloth pieces during menstruation. Conclusions:There is a need to increase awareness among women and the broader community about different epidemiologicalfactors that may be responsible for increased risk of gynecological malignancies.     

Mucormycete infection or colonisation: experience of an Australian tertiary referral centre

Mucormycosis is associated with significant morbidity and mortality. We reviewed patients with mucormycete isolated at Alfred Health, Australia. A retrospective review of 66 patients with mucormycete(s) identified, between 1 April 2008 and 30 June 2014. Baseline demographic, microbiological, radiological, treatment/outcome data were recorded. Site of isolation was sinopulmonary in 77% and skin/soft tissue in 21%. A total of 32% of cases were proven‐IFD, 12% probable‐IFD and 56% were defined as no‐IFD (or colonisation). Rhizopus spp. was identified in 48%. Comparing probable/proven‐IFD with no‐IFD/colonisation, more patients were postallogeneic stem cell transplantation (28% vs. 0%, P < 0.01) and were receiving immunosuppressive therapy (59% vs. 24%, P < 0.01) including prednisolone >20 mg daily (24% vs. 5%, P = 0.04). A total of 93% of patients with proven/probable IFD received treatment while 30% of no‐IFD/colonisation were treated. A total of 72% of patients with proven/probable IFD and 92% of those with colonisation had no further mucormycete isolated. Thirty day mortality was higher in the proven/probable‐IFD cohort (24%) compared with no‐IFD/colonisation (3%) (P = 0.02). Mucormycosis remains uncommon, with 56% of cases not associated with clinical infection. Immunosuppressive therapy remains strongly associated with mucormycosis. Mortality remains high in those with proven/probable IFD.     

Current scenario of cryptococcosis and antifungal susceptibility pattern in India: a cause for reappraisal

This study analysed the spectrum, antifungal susceptibility pattern, clinical course and molecular epidemiology of cryptococcosis. Four hundred and thirty-nine samples obtained from 378 meningitis patients were processed by standard procedures. Minimum inhibitory concentration (MIC) of fluconazole and amphotericin B for the isolates was tested by broth micro dilution and by E-strip method. Molecular analysis by random amplified polymorphic DNA-PCR of eight isolates was performed using M13 primer. Cryptococcosis was diagnosed in 35 patients [HIV-1 seropositive (19) and apparently immunocompetent (16)]. Cryptococcus neoformans var. neoformans (serotype A and D) was the predominant isolate on phenotypic identification. Three C. neoformans var. gattii were isolated from HIV-1 seropositive (2) and apparently immunocompetent (1) patients. MIC 90 for amphotericin B and fluconazole were 1 and 8 μg ml⁻¹ respectively. On RAPD-PCR, less diversity was seen among Indian isolates. AIDS remains the single most important risk factor for cryptococcosis. Rising MIC of the available induction and maintenance drugs is of grave concern. The DNA typing technique showed less diversity among Indian strains. Routine surveillance and application of molecular typing methods are crucial to know the baseline and existing pattern of cryptococcosis.     

Rhizopus oligosporus as a Cause of Mucormycosis in Man: Rhizopus oligospovus als Mucormykose-Erreger beim Menschen

After a fracture of the spinal column a 49-year-old male developed a mucormycosis due to Rhizopus oligosporus. This appears to be the first report of a disease caused by this thermotolerant Rhizopus species in a human being.     

Mucormycosis in paediatric patients: demographics, risk factors and outcome of 12 contemporary cases

Mucormycosis is associated with high morbidity and mortality and is perceived as an emerging fungal infection. However, contemporary paediatric data are limited. We present a series of paediatric cases of mucormycosis reported from Germany and Austria collected within a voluntary epidemiological survey through standardised, anonymized case report forms. Twelve cases were reported between January 2004 and December 2008 (six men; mean age: 12.6 years, range: 0.1-17 years). Mucormycosis was proven in nine, and probable in three cases. Isolates included Lichtheimia (syn. Absidia pro parte, Mycocladus) (five), Rhizopus (three) and Mucor (one) species. Infection was limited to soft tissue in three cases, the lung in two cases, and an infected thrombus in one case; rhinocerebral disease was found in three cases, and pulmonary-mediastinal, pulmonary-cerebral and soft tissue-cerebral involvement in one case each. All three patients with isolated soft tissue infection were cured, whereas seven of the remaining patients died (one patient without follow-up). The overall mortality rate was 67%. While these data cannot provide conclusive data on incidence and disease burden of mucormycosis in paediatric patients, they reflect the continuing threat of these infections to immunocompromised patients and the need for improved diagnosis and management.     

Determinants of Tobacco Cessation Behaviour among Smokersand Smokeless Tobacco Users in the States of Gujarat andAndhra Pradesh,India

Background: This study was undertaken to identify the socio-demographic determinants of quit attemptsamong smokers and smokeless tobacco users to identify correlates of tobacco cessation behaviour in IndiaMaterials and Methods: This was a cross-sectional study for the outcome of quit attempts made by current tobaccousers in last 12 months in twelve districts in two states. Simple and multivariable logistic regression analysis wasused to obtain the odds ratios (ORs) of socio-demographic variables (age, gender, education, occupation, socioeconomicstatus, community, area, type of family) and tobacco user status (smoker/smokeless). Results: In thecombined analysis, a smoker had higher predicted probability of attempting quitting (OR- 1.41,CI 1.14 -1.90),in comparison to a smokeless tobacco user and a tobacco user in the state of Gujarat was less likely to attemptquitting than a user in Andhra Pradesh (OR-0.60, CI 0.47-0.78). The probability of making a quit attempt washigher among tobacco users who were more educated (OR-1.40, CI 1.04-1.94), having a higher socio-economicstatus (SES) (OR-2.39, CI 1.54-3.69), and belonging to non-agricultural labourer occupational group (OR-1.90,CI 1.29-2.78). The effects were maintained even after adjusting for all other variables. In disaggregated analysis,findings were similar except in smokeless as a separate group, education level was not significantly associatedwith quit attempts and with lower odds (OR-0.91, CI 0.58-1.42). Conclusions: This is one of the first studies toprovide useful insight into potential determinants for quit attempts of tobacco users in India including smokelesstobacco users, exploring the socio-demographic patterning of correlates of quit attempts.     

Chronic pulmonary aspergillosis in a tertiary care centre in Spain: A retrospective,observational study

The aim of this study was to describe the characteristics of patients with chronic pulmonary aspergillosis (CPA) in a tertiary care centre in Spain. Retrospective cohort study of all patients diagnosed with CPA between January 2010 and December 2015. The patients were identified through the Microbiology Registry. Demographic, clinical, laboratory, radiological, microbiological and clinical data were recorded. Patients were followed up for 12 months. Fifty‐three patients were included; median age was 61.5 years. Forty‐seven had a lung condition, 25 suffered from COPD, 19 an active malignancy, 10 had previous pulmonary tuberculosis and 9 lung interstitial disease. Twenty‐eight patients presented with chronic cavitary pulmonary form (CCPA) and 20 with subacute invasive aspergillosis (SAIA). Species identified were A fumigatus (34), A niger (5), A terreus (4) and A flavus (3). All‐cause 1‐year mortality was 56%. Predictors of mortality were cancer history (OR, 9.5; 95% CI, 2.54‐35.51; P < 0.01) and SAIA (OR, 5.49; 95% CI, 1.49‐19.82; P < 0.01). Previous pulmonary tuberculosis, surgery for the treatment of CPA and CCPA were found to be associated with lower mortality (OR, 0.05; 95% CI, <0.01‐0.47; P < 0.01; OR, 0.16; 95% CI, 0.03‐0.88; P = 0.035 and OR 0.2, 95% CI, 0.01‐0.67; P = 0.01, respectively). This is the first study providing an overview of the features of CPA in patients from Spain. CCPA was the most frequent form of CPA and A fumigatus the most frequently isolated species. Patients with cancer history and SAIA had a worse prognosis.