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Phycomycosis as postoperative complication of urologic surgery
PHYCOMYCOSIS AS POSTOPERATIVE COMPLICATION OF UROLOGIC SURGERY S . HEINEMANN, M .D. Hotel Dieu Hospital, El Paso, Texas
ABSTRACT -A case of phycomycosis (Mucor) complicating urologic surgery is presented . It is a rare disease that is rapidly fatal, though caused by a usually benign saphophytic fungus . No previous urologic surgical cases have been found in the literature where Mucor has been a postoperative complication .
Phycomycetes are true fungi and include the Rhizopus, Absidia, and Mucor genera . They occur in nature as bread molds, laboratory contaminants, on fruit, and in the human are harmless saprophytes . When they become pathogens, they are one of the most fatal infections known with a mortality of 50 to 80 per cent even with the use of amphotericin B . They attack the brain, orbital area, lung, gastrointestinal tract, and arteries . Phycomycosis (mucormycosis) has never before been reported as a complication of urologic surgery . Case Report The patient, age sixty-six, was seen in acute urinary retention in 1965 after taking propantheline (Pro-banthine) for spastic colitis . There was a history of obstructive uropathy for several years . Several previous episodes of difficulty in voiding had followed the use of propantheline or antihistamines which were used for allergies . An intravenous pyelograin confirmed the presence of an enlarged prostate and a small calculus in a calyx of the right kidney. Barium enema showed a spastic colon with a few diverticula. Physical examination was negative except for prostatic enlargement (3+) which was smooth, movable, and of normal consistency . The patient was admitted to the hospital, and results of laboratory workup, electrocardiogram, and chest x-ray examination were normal . Under general anesthesia 23 .8 Gm . of prostatic tissue were resected . In the recovery
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VOLUME XVII, NUMBER I
room approximately three hours later hypotension developed (60/40 mm . Hg) . He responded to hydrocortisone (Solu-Cortef) and metaraminol (Aramine), and two hours later his blood pressure was 110/40 mm . Hg. About eight hours postoperative the patient became oliguric and mannitol was given intravenously . The patient continued to be oliguric, but he was responding to the mannitol . Approximately three days later the patient's potassium and blood urea nitrogen had risen, and peritoneal dialysis was started . On the fifth postoperative day he had normal electrolytes and increased urine output . On the seventeenth postoperative day chest pain with difficulty in respiration developed . Chest x-ray films were normal . His difficulty with respiration and chest pain continued, and two days later a chest x-ray examination revealed a right pleural effusion with infiltration of the right lower lobe . A right exophthalmos developed suddenly on the twentieth postoperative day, the cause of which was unexplainable . On the twenty-first postoperative day peritoneal dialysis was again started after oliguria developed . He died on the twentysecond postoperative day .
Autopsy findings The prostate showed benign prostatic hyperplasia, and the kidney showed a healing lower nephron nephrosis . The findings relate to the lesions of mucormycosis as follows .
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(A) Pulmonary vein with formation of thrombus and phlebitis; wall infiltration by hyphae of Mucor . High-power views showing (B) monocytes and hyphae of Mucor, and (C) wall of pulmonary artery showing hyphae . FIGURE 1 .
Lungs : "In the hilar region of both lungs is a tracheobronchitis with adjacent consolidation . This process is not present in other areas . Also in the hilar area the right pulmonary artery shows a large atypical thrombus which is tanyellow, fibrinous, and jelly-like . The thrombus has a hollow center, being formed circumferentially. It is adherent to the endothelium which is not thickened or ulcerated . There was a 2-cm . infarct in the right middle lobe . Microscopic sections reveal an overt involvement by mucormycosis . This is characterized by hyphae which are nonseptated and quite broad (2-20 mm.). They stain positive with a PAS stain . The large hyphae invade the walls of blood vessels, bronchi, and lie free in alveolar spaces (Fig . 1) . Over the intimal surface there are masses of the hyphae producing a blood clot . There is extensive involvement of the adjacent lung parenchyma with a large amount of hemorrhage and scattered hyphae . The tracheobronchial mucosa shows a hemorrhagic necrotizing debris with scattered hyphae . Additional sections of the lung reveal congestion and widespread focal areas of involvement by mucormycosis ."
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Brain : "There is a focal ecchymosis of the meninges over the right inferior frontal lobe . Multiple sections reveal cerebral mucormycosis characterized by involvement of small and large cortical vessels, with invasion of the muscular coat and luminal thrombosis (Fig . 2) . The process extends into vessels deep within the cerebrum . In focal areas there is an infiltration beneath the meninges of neutrophilic leukocytes characterizing a focal meningitis secondary to mucormycosis ." Frontal sinuses : "These reveal a hemorrhagic or necrotizing sinusitis characterized by grumous red-tan material . Tissue removed from
FIGURE 2 . Small subarachnoid venule with erythrocytes and leukocytes . Bluish discoloration within vascular wall accompanied by infiltration of nonseptate hyphae of Rhizopus species, consistent with mucormycosis .
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the right paranasal sinus reveals an exhorbitant amount of young edematous granulation tissue with nonspecific chronic inflammation and mucormvcosis ." Comments Mucormycosis has been reported as a complication of heart valve replacement surgery,' in cases of renal transplantation, 2 following dental extraction, 1 .4 in severe diabetics, and in neurosurgery . 5 One case has been reported after open head traumas It may infect the skin, external ear, endocardium, or produce pulmonary fungous balls . Mucormycosis was once limited as a complication of chronic debilitating diseases . The patients with diabetes 3 .4 .6 immune deficiencies, leukemia and terminal cancer, or bums were its victims .' Now with the use of antibiotics, corticosteroids, and antileukemic drugs, its frequency has increased, and it is becoming a postoperative complication, The Phycomycetes are a group of fungi characterized by broad, nonseptate, uneven, coenocytic hyphae in tissues . Distribution is world wide and soil is the normal habitat . Infection is by inhalation of spores, by ingestion, or through the skin . There is a no man-to-man or animal-to-man contagion . Mucormycosis has a rapid onset, and diagnosis is difficult . Smith and Kirchner' list six pathognomonic signs and symptoms for diagnosis : 1 . Dark, blood-tinged nasal discharge of brief duration, with facial pain on the involved side . 2 . Soft periorhital or perinasal swelling progressing to induration and discoloration due to ischemia .
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VOLUME XVII, NUMBER 1
3 . Ptosis of the lid and proptosis of the globe, dilatation and fixation of the pupil, and loss of mobility of the globe . 4 . Progressive lethargy . 5 . Black, necrotic palate, alveolar ridge, or turbinates, easily mistaken for dried blood . 6 . Loss of corneal reflex with facial weakness or numbness . Biopsy is the only fast reliable diagnostic method . Treatment is with amphotericin B (Fungizone), supportive therapy, control of diabetes, as well as reversal of ketoacidosis . 3 Drug therapy is a long process, and the drug is extremely nephrotoxic . 1900 N . Oregon Street El Paso, Texas 79902
ACKNOWLEDGMENT .
To Dr . Stuart Wilson, who did
the photography. References 1 . Khicha GJ, Berroya RB, Escano FB Jr, and Lee CS : Muconnycosis in a mitral prosthesis, J . Thorac. Cardiovase . Surg .
63 :903 (1972) . 2 . Haim S, et al : Rhinocerebral muconnycosis following kidney transplantation, Isr . J . Med . Sci . 6 :646 (1970) . 3 . Eilderton TE : Fatal post-extraction cerebral mucormycosis in an unknown diabetic, J . Oral Surg . 32 : 297 (1974) . 4 . Limongelli WA, et al : Successful treatment of mucocutaneous muconnycosis after dental extractions in a patient with uncontrolled diabetes, ibid. 33 : 705 (1975). 5. Ignelzi RL, and VanderArk GD: Cerebral mucormycosis following open head trauma, J . Neurosurg . 42 : 593 (1975) . 6 . McBride RA, Corson JM, and Dammin GJ : Mucormycosis, 2 cases of disseminated disease with cultural identification Rhizopus, Am . J . Med . 28 : 832 (1960) . 7 . Prout GR Jr, and Goddard AR : Mucormycosis limited to
kidney and cured with amphotericin B therapy, TBC ; diagnosis later, pulmonary, N . Engl . J . Med . 263 : 1246 (1960) . 8 . Smith HW, and Kirchner JA : Cerebral mucormycosis, Arch . Otolaryagol . 68 : 715 (1958) .
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ABSTRACT -A case of phycomycosis (Mucor) complicating urologic surgery is presented . It is a rare disease that is rapidly fatal, though caused by a usually benign saphophytic fungus . No previous urologic surgical cases have been found in the literature where Mucor has been a postoperative complication .
Phycomycetes are true fungi and include the Rhizopus, Absidia, and Mucor genera . They occur in nature as bread molds, laboratory contaminants, on fruit, and in the human are harmless saprophytes . When they become pathogens, they are one of the most fatal infections known with a mortality of 50 to 80 per cent even with the use of amphotericin B . They attack the brain, orbital area, lung, gastrointestinal tract, and arteries . Phycomycosis (mucormycosis) has never before been reported as a complication of urologic surgery . Case Report The patient, age sixty-six, was seen in acute urinary retention in 1965 after taking propantheline (Pro-banthine) for spastic colitis . There was a history of obstructive uropathy for several years . Several previous episodes of difficulty in voiding had followed the use of propantheline or antihistamines which were used for allergies . An intravenous pyelograin confirmed the presence of an enlarged prostate and a small calculus in a calyx of the right kidney. Barium enema showed a spastic colon with a few diverticula. Physical examination was negative except for prostatic enlargement (3+) which was smooth, movable, and of normal consistency . The patient was admitted to the hospital, and results of laboratory workup, electrocardiogram, and chest x-ray examination were normal . Under general anesthesia 23 .8 Gm . of prostatic tissue were resected . In the recovery
UROLOGY
/
JANUARY 1981
/
VOLUME XVII, NUMBER I
room approximately three hours later hypotension developed (60/40 mm . Hg) . He responded to hydrocortisone (Solu-Cortef) and metaraminol (Aramine), and two hours later his blood pressure was 110/40 mm . Hg. About eight hours postoperative the patient became oliguric and mannitol was given intravenously . The patient continued to be oliguric, but he was responding to the mannitol . Approximately three days later the patient's potassium and blood urea nitrogen had risen, and peritoneal dialysis was started . On the fifth postoperative day he had normal electrolytes and increased urine output . On the seventeenth postoperative day chest pain with difficulty in respiration developed . Chest x-ray films were normal . His difficulty with respiration and chest pain continued, and two days later a chest x-ray examination revealed a right pleural effusion with infiltration of the right lower lobe . A right exophthalmos developed suddenly on the twentieth postoperative day, the cause of which was unexplainable . On the twenty-first postoperative day peritoneal dialysis was again started after oliguria developed . He died on the twentysecond postoperative day .
Autopsy findings The prostate showed benign prostatic hyperplasia, and the kidney showed a healing lower nephron nephrosis . The findings relate to the lesions of mucormycosis as follows .
65
(A) Pulmonary vein with formation of thrombus and phlebitis; wall infiltration by hyphae of Mucor . High-power views showing (B) monocytes and hyphae of Mucor, and (C) wall of pulmonary artery showing hyphae . FIGURE 1 .
Lungs : "In the hilar region of both lungs is a tracheobronchitis with adjacent consolidation . This process is not present in other areas . Also in the hilar area the right pulmonary artery shows a large atypical thrombus which is tanyellow, fibrinous, and jelly-like . The thrombus has a hollow center, being formed circumferentially. It is adherent to the endothelium which is not thickened or ulcerated . There was a 2-cm . infarct in the right middle lobe . Microscopic sections reveal an overt involvement by mucormycosis . This is characterized by hyphae which are nonseptated and quite broad (2-20 mm.). They stain positive with a PAS stain . The large hyphae invade the walls of blood vessels, bronchi, and lie free in alveolar spaces (Fig . 1) . Over the intimal surface there are masses of the hyphae producing a blood clot . There is extensive involvement of the adjacent lung parenchyma with a large amount of hemorrhage and scattered hyphae . The tracheobronchial mucosa shows a hemorrhagic necrotizing debris with scattered hyphae . Additional sections of the lung reveal congestion and widespread focal areas of involvement by mucormycosis ."
66
Brain : "There is a focal ecchymosis of the meninges over the right inferior frontal lobe . Multiple sections reveal cerebral mucormycosis characterized by involvement of small and large cortical vessels, with invasion of the muscular coat and luminal thrombosis (Fig . 2) . The process extends into vessels deep within the cerebrum . In focal areas there is an infiltration beneath the meninges of neutrophilic leukocytes characterizing a focal meningitis secondary to mucormycosis ." Frontal sinuses : "These reveal a hemorrhagic or necrotizing sinusitis characterized by grumous red-tan material . Tissue removed from
FIGURE 2 . Small subarachnoid venule with erythrocytes and leukocytes . Bluish discoloration within vascular wall accompanied by infiltration of nonseptate hyphae of Rhizopus species, consistent with mucormycosis .
UROLOGY
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JANUARY 1981 / VOLUME XVII, NUMBER 1
the right paranasal sinus reveals an exhorbitant amount of young edematous granulation tissue with nonspecific chronic inflammation and mucormvcosis ." Comments Mucormycosis has been reported as a complication of heart valve replacement surgery,' in cases of renal transplantation, 2 following dental extraction, 1 .4 in severe diabetics, and in neurosurgery . 5 One case has been reported after open head traumas It may infect the skin, external ear, endocardium, or produce pulmonary fungous balls . Mucormycosis was once limited as a complication of chronic debilitating diseases . The patients with diabetes 3 .4 .6 immune deficiencies, leukemia and terminal cancer, or bums were its victims .' Now with the use of antibiotics, corticosteroids, and antileukemic drugs, its frequency has increased, and it is becoming a postoperative complication, The Phycomycetes are a group of fungi characterized by broad, nonseptate, uneven, coenocytic hyphae in tissues . Distribution is world wide and soil is the normal habitat . Infection is by inhalation of spores, by ingestion, or through the skin . There is a no man-to-man or animal-to-man contagion . Mucormycosis has a rapid onset, and diagnosis is difficult . Smith and Kirchner' list six pathognomonic signs and symptoms for diagnosis : 1 . Dark, blood-tinged nasal discharge of brief duration, with facial pain on the involved side . 2 . Soft periorhital or perinasal swelling progressing to induration and discoloration due to ischemia .
UROLOGY / JANUARY 1981
/
VOLUME XVII, NUMBER 1
3 . Ptosis of the lid and proptosis of the globe, dilatation and fixation of the pupil, and loss of mobility of the globe . 4 . Progressive lethargy . 5 . Black, necrotic palate, alveolar ridge, or turbinates, easily mistaken for dried blood . 6 . Loss of corneal reflex with facial weakness or numbness . Biopsy is the only fast reliable diagnostic method . Treatment is with amphotericin B (Fungizone), supportive therapy, control of diabetes, as well as reversal of ketoacidosis . 3 Drug therapy is a long process, and the drug is extremely nephrotoxic . 1900 N . Oregon Street El Paso, Texas 79902
ACKNOWLEDGMENT .
To Dr . Stuart Wilson, who did
the photography. References 1 . Khicha GJ, Berroya RB, Escano FB Jr, and Lee CS : Muconnycosis in a mitral prosthesis, J . Thorac. Cardiovase . Surg .
63 :903 (1972) . 2 . Haim S, et al : Rhinocerebral muconnycosis following kidney transplantation, Isr . J . Med . Sci . 6 :646 (1970) . 3 . Eilderton TE : Fatal post-extraction cerebral mucormycosis in an unknown diabetic, J . Oral Surg . 32 : 297 (1974) . 4 . Limongelli WA, et al : Successful treatment of mucocutaneous muconnycosis after dental extractions in a patient with uncontrolled diabetes, ibid. 33 : 705 (1975). 5. Ignelzi RL, and VanderArk GD: Cerebral mucormycosis following open head trauma, J . Neurosurg . 42 : 593 (1975) . 6 . McBride RA, Corson JM, and Dammin GJ : Mucormycosis, 2 cases of disseminated disease with cultural identification Rhizopus, Am . J . Med . 28 : 832 (1960) . 7 . Prout GR Jr, and Goddard AR : Mucormycosis limited to
kidney and cured with amphotericin B therapy, TBC ; diagnosis later, pulmonary, N . Engl . J . Med . 263 : 1246 (1960) . 8 . Smith HW, and Kirchner JA : Cerebral mucormycosis, Arch . Otolaryagol . 68 : 715 (1958) .
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