Abstract
Introduction
The fungi pertaining to order Mucorales usually cause an acute form of clinical disease called mucormycosis. A primary chronic presentation in an immunocompetent patient is a rare form of mucormycosis. Mucor irregularis is known for causing chronic cutaneous infections geographically confined to Asia, mainly in China. We describe a case of primary chronic cutaneous mucormycosis caused by M. irregularis from a new geographical niche in India, highlighting changing aspects of its epidemiology.
Case Presentation
The patient was a farmer with a history of skin lesions over the lower limb for the past 6 years. The biopsy taken from the lesions showed pauci-septate hyphae with right-angle branching on KOH wet mount as well as special fungal stains. On fungal culture, greyish-white cottony mycelial growth of Mucormycetes was obtained. The strain was finally identified as M. irregularis on macro- and microscopic features on 2 % MEA and DNA sequencing. The antifungal susceptibility was done using EUCAST broth microdilution method and was found to be susceptible to commonly used antifungal agents. The patient was started on oral itraconazole and saturated solution of potassium iodide (SSKI). While undergoing treatment for 2 months, he was lost to follow-up, however, after a year when he recently visited the hospital; the disease got completely healed with no new crops of skin lesions.
Conclusion
Mucoralean fungi should also be suspected in cases with chronic presentation, in immunocompetent host, as there is emergence of such fungi in new endemic areas, particularly located in Asia. The role of other antifungal agents apart from amphotericin B for the treatment of chronic mucormycosis needs to be explored.
References
Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis. 2012;54:S23–34.
Kang D, Jiang X, Wan H, Ran Y, Hao D, Zhang C. Mucor irregularis infection around the inner canthus cured by amphotericin B: a case report and review of published literatures. Mycopathologia. 2014;178:129–33.
Xia XJ, Shen H, Liu ZH. Primary cutaneous mucormycosis caused by Mucor irregularis. Clin Exp Dermatol. 2015; doi:10.1111/ced.12642 [Epub ahead of print].
Hemashettar BM, Patil RN, O’Donnell K, Chaturvedi V, Ren P, Padhye AA. Chronic rhinofacial mucormycosis caused by Mucor irregularis (Rhizomucor variabilis) in India. J Clin Microbiol. 2011;49:2372–5.
Patil AB, Chandramohan K, Shivaprakash MR, Nadgir SD, Lakshminarayana SA. Rhizomucor variabilis: a rare causative agent of primary cutaneous zygomycosis. Indian J Med Microbiol. 2013;31:302–5.
Oliveira-Neto MP, Da Silva M, Fialho Monteiro PC, Lazera M, de Almeida Paes R, Novellino AB, et al. Cutaneous mucormycosis in a young, immunocompetent girl. Med Mycol. 2006;44:567–70.
Chander J, Stchigel AM, Alastruey-Izquierdo A, Jayant M, Bala K, Rani H, et al. Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales). Rev Iberoam Micol. 2015;32:93–8.
Zheng RY, Chen CQ. A non-thermophilic Rhizomucor causing human primary cutaneous mucormycosis. Mycosystema. 1991;4:45–57.
Alvarez E, Cano J, Stchigel AM, Sutton DA, Fothergill AW, Salas V, et al. Two new species of Mucor from clinical samples. Med Mycol. 2011;49:62–72.
Lu XL, Najafzadeh MJ, Dolatabadi S, Ran YP, Gerrits van den Ende AH, Shen YN, et al. Taxonomy and epidemiology of Mucor irregularis, agent of chronic cutaneous mucormycosis. Persoonia. 2013;30:48–56.
Yamaguchi S, Okubo Y, Katano A, Sano A, Uezato H, Takahashi K. Primary cutaneous mucormycosis caused by Mucor irregularis in an elderly person. J Dermatol. 2015;42:210–4.
Tomita H, Muroi E, Takenaka M, Nishimoto K, Kakeya H, Ohno H, et al. Rhizomucor variabilis infection in human cutaneous mucormycosis. Clin Exp Dermatol. 2011;36:312–4.
Matsudate Y, Murao K, Urano Y, Yarita K, Kamei K, Takeichi H, Kubo Y. Primary cutaneous mucormycosis caused by Mucor irregularis in an immunocompetent patient. J Dermatol. 2015;42:267–8.
Ribeiro NFF, Cousin GCS, Wilson GE, Butterworth DM, Woodwards RT. Lethal invasive mucormycosis: case report and recommendations for treatment. Int J Oral Maxillofac Surg. 2001;30:156–9.
Schell WA, O’Donnell K, Alspaugh JA. Heterothallic mating in Mucor irregularis and first isolate of the species outside of Asia. Med Mycol. 2011;49:714–23.
Li DM, Lun LD. Mucor irregularis infection and lethal midline granuloma: a case report and review of published literature. Mycopathologia. 2012;174:429–39.
Xia ZK, Wang WL, Yang RY. Slowly progressive cutaneous, rhinofacial and pulmonary mucormycosis caused by Mucor irregularis in an immunocompetent woman. Clin Infect Dis. 2013;56:993–5.
Rammaert B, Angebault C, Scemla A, Fraitag S, Lerolle N, Lecuit M, et al. Mucor irregularis-associated cutaneous mucormycosis: case report and review. Med Mycol Case Rep. 2014;6:62–5.
Abuali MM, Posada R, Del Toro G, Roman E, Ramani R, Chaturvedi S, et al. Rhizomucor variabilis var. regularior and Hormographiella aspergillata infections in a leukemic bone marrow transplant recipient with refractory neutropenia. J Clin Microbiol. 2009;47:4176–9.
Zhao Y, Zhang QQ, Li L, Zhu JH, Kang K, Chen LJ, et al. Primary cutaneous mucormycosis caused by Rhizomucor variabilis in an immunocompetent patient. Mycopathologia. 2009;168:243–7.
Costa RO, Macedo PM, Carvalhal A, Bernardes-Engemann AR. Use of potassium iodide in dermatology: updates on an old drug. An Bras Dermatol. 2013;88:396–402.
Chander J. Textbook of Medical Mycology. 3rd ed. New Delhi: Mehta Publishers; 2009.
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Chander, J., Kaur, M., Bhalla, M. et al. Changing Epidemiology of Mucoralean Fungi: Chronic Cutaneous Infection Caused by Mucor irregularis . Mycopathologia 180, 181–186 (2015). https://doi.org/10.1007/s11046-015-9908-z
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DOI: https://doi.org/10.1007/s11046-015-9908-z