Zygomycosis caused byCunninghamella bertholletiaein a kidney transplant recipient

Abstract

Infections caused by Cunninghamella bertholletiae are rare but severe. Only 32 cases have been reported as yet, but in 26 of these this species was a contributing cause of the death of the patient. This opportunistic mould in the order Mucorales infects immunocompromized patients suffering from haematological malignancies or diabetes mellitus, as well as solid organ transplant patients. The lung is the organ most often involved. Two cases of primary cutaneous infection have been previously reported subsequent to soft-tissue injuries. We report a case of primary cutaneous C. bertholletiae zygomycosis in a 54-year-old, insulin-dependent diabetic man who was treated with tacrolimus and steroids after kidney transplantation. No extracutaneous involvement was found. In this patient, the infection may have been related to insulin injections. The patient recovered after an early surgical excision of the lesion and daily administration of itraconazole for 2 months. This case emphasizes the importance of an early diagnosis of cutaneous zygomycosis, which often presents as necrotic-looking lesions. Prompt institution of antifungal therapy and rapid surgical intervention are necessary to improve the prospects of patients who have contracted these potentially severe infections.

Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management

“…Itraconazole is the only marketed azole drug that has in vitro activity against Mucorales (147). There are case reports of successful therapy with itraconazole alone (36,125). However, as mentioned above, itraconazole prophylaxis has been described as a risk factor for breakthrough mucormycosis (130).…”

“…These infections occur in patients with disrupted cutaneous barriers, as a result of either traumatic implantation of soil, maceration of skin by a moist surface (5,119), or even via direct access through intravenous catheters or subcutaneous injections (4,73,125). These cases illustrate an alarming trend in the epidemiology of mucormycosis.…”

“…A typical case results from traumatic implantation of soil, for example, as a result of a motor vehicle accident or penetrating injury with plant material (e.g., a thorn) (4,119). In diabetic and immunocompromised patients, cutaneous lesions may also arise at insulin injection or catheter insertion sites (73,125). Contaminated surgical dressings have also been implicated as a source of cutaneous mucormycosis (43,100).…”

Mucormycosis Caused by Unusual Mucormycetes, Non-Rhizopus, -Mucor, and -Lichtheimia Species

“…Primary cutaneous (40,267) and cutaneo-articular (217) cases of mucormycosis caused by C. bertholletiae were reported following percutaneous inoculation or trauma in patients with diabetes mellitus, renal transplant recipients, and an i.v. drug abuser with AIDS (40,217,267).…”

“…Percutaneous inoculation of C. bertholletiae, although less common, has been described from the inpatient (218,251), outpatient (262), and community (122,267) settings, following pleural taps (218), peritoneal dialysis (262), use of blood glucose self-monitoring equipment (122), and insulin injections (267). Several adhesive products used in hospitals have been linked with the development of Mucormycetes wound infections (40,279,280), including C. bertholletiae infections (218).…”