Figure 1064

Mucormycosis is caused by fungi of the order Mucorales, including Rhizopus, Absidia, and Mucor. Mucorales are ubiquitous saprophytes found in the soil and on decaying organic material, including bread and fruit. Human infection is believed to be caused by the inhalation of spores that initially land on the oral and nasal mucosa. Direct inoculation into tissues, however, has been reported.

Most of the spores, once in the tissue, are contained by the phago-cytic response. If this fails, as it often does in patients with diabetes mellitus and those otherwise immunosuppressed, germination begins and hyphae develop. The hyphae, as shown in the micrograph, are large, nonseptate, rectangular, and branch at right angles. Infection begins with the invasion of blood vessels, which causes necrosis and dissemination of the infection. The most common site of involvement is the rhino-orbital-cerebral area, accounting for approximately 70% of cases; however, pulmonary, cutaneous, gastrointestinal, and disseminated infection may be seen. The chest radiograph during pulmonary infections may show an infiltrate, nodule, cavitary lesion, or pleural effusion. Gastric involvement may range from colonization of peptic ulcers to infiltrative disease with vascular invasion causing perforation. Although classic for mucormycosis, a black eschar of the skin, nasal mucosa, or palate is present in only about 20% of patients early in the course of the disease and cannot be relied on for assistance in early diagnosis. Survival is dependent on early diagnosis. Diagnosis is by biopsy with classic histologic findings and by culture of tissue. Treatment includes amphotericin B, surgical removal of the lesion, packing of the sinus areas with amphotericin B-soaked packs, and perhaps hyperbaric oxygen. Liposomal amphotericin B has also been effective. Treatment must include both surgery and amphotericin B.

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