Zygomycosis an emerging problem – 2 case reports

e100 diagnostic techniques such as fungal antigen testing and PCR, diagnosis is still often based on clinical and radiological findings alone, and initial treatment is usually empirical. Here we present the case of a neutropenic patient with mantle cell lymphoma who was admitted to hospital with fevers, nausea and fatigue. He subsequently developed a respiratory syndrome and sepsis as a result of clinically and radiologically diagnosed invasive fungal infection (Image 1: CT transverse sections revealing multiple pulmonary nodules). In spite of early intensive empirical antibiotic and antifungal chemotherapy with amphoteracin B, he died rapidly. Pre-mortem sputum at room temperature and at 37  C on Sabouraud agar grew a single filamentous mould of the class Zygomycete with characteristic properties of Cunninghamella spp. (Image 2: microscopic and macroscopic appearances of Cunninghamella spp.). Post mortem pulmonary samples revealed angio-invasive broad ribbon-like hyphae branching at 90  consistent with Cunninghamella spp.. In addition, there was a second type of mould seen, with appearances of Aspergillus spp. (Image 3: histopathology sections of pulmonary tissue). Together, the microbiology and histopathology findings were suggestive of dual fungal pathology. This case highlights the diagnostic and management difficulties posed by seriously ill immunocompromised patients with presumed fungal infection. In particular, it illustrates an interesting and unusual case of mixed mycosis. In the new era of increasing voriconazole use both as prophylaxis and in treatment of IFI, it is important to remember the increasing incidence of rare but serious zygomycoses which are not covered by this new regime. As diagnostic methods such as fungal PCR and antigen detection become more standardized in their use, they may help guide the early and appropriate choice of anti-fungal agent and reduce the currently unacceptably high mortality of this disease.

P 124 A PROVERBIAL PAIN IN THE NECK e OR WAS IT? Premchand Nikhil, Schmid Matthias, McCrossan Roopa, Snow Michael Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP We present the case of an 84 year old man who initially presented to hospital in early March with a 6 week history of pains in his head and neck, associated with dizziness. His only significant previous medical history was of left laryngeal carcinoma, treated hypertension and cervical spondylosis with no history of diabetes or immunocompromise. The initial impression was that he was suffering from postural hypotension secondary to anti-hypertensives and that the pain was due to chronic left ear perforation with superimposed infection for which he was already under ENT follow up. Once the dizziness had abated he was discharged home with an early clinic appointment. During that

Abstracts admission a CT scan of his head was noted to show mild generalised cerebral atrophy with no bony abnormalities. He returned to hospital three weeks later with further similar symptoms and also complained of diplopia. At this stage, staff noted that he was paranoid and he was felt to be very preoccupied with his symptoms. Clinically he was found to have a left 6th cranial nerve palsy and at that stage his inflammatory markers were elevated (ESR 110 mm/hr, CRP 85 mg/L) and he had a normocytic anaemia. MRI scanning was undertaken to investigate the cranial nerve palsy further and this suggested small vessel ischaemia and surprisingly suggested that there was a left dural abnormality involving the clivus of inflammatory or infectious nature. At this stage biopsy was felt to be too risky so treatment was initiated with a reducing course of dexamethasone and an anti-pseudomonal penicillin. The patient seemed to make a dramatic response within days and his inflammatory markers decreased significantly. Unfortunately 10 days after starting antibiotics the patient deteriorated rapidly over the course of a morning with vomiting followed by a rapid reduction in his GCS. Within hours he suffered a respiratory arrest which he did not survive. A post mortem examination confirmed that the patient had suffered a haemorrhagic stroke involving the pons and macroscopically the left sphenoid bone and clivus were felt to be nodular. Further histological examination of the brain tissue and bone revealed a dense inflammatory process and fungal elements consistent with Mucor and this was felt to have infiltrated the blood vessels resulting in the stroke. Although Mucor is recognised to cause sinus, orbital and deep facial soft tissue infiltration especially in diabetic or immunocompromised patients, there are only isolated case reports of it causing base of skull osteomyelitis. In this case we had not considered fungal pathogens to be a likely cause of the imaging abnormalities, however at that stage we had neglected the salient fact that the patient had a chronic left eardrum perforation. Furthermore, on retrospective post mortem analysis of all of the microbiology samples taken from the patient, an ear swab taken by his GP in February had grown Aspergillus fumigatus and Staphylococcus aureus. Had we borne the anatomical defect in mind and looked back at records prior to admission to hospital then we may have considered and treated the patient for a fungal infection at an earlier opportunity. Thus, the lessons we learned were: ‘‘When faced with an unusual problem, expect the unexpected and consider that simple anatomical defects may have greater significance than first assumed. Do not neglect past information in pursuit of a future cure.’’

P 125 ZYGOMYCOSIS AN EMERGING PROBLEM e 2 CASE REPORTS Albur M, Wembri J, Hovenden J, Wood H, Billous R James Cook University Hospital Middlesbrough Introduction: Zygomycetes are ubiquitous fungi that can cause invasive disease in susceptible hosts, with a wide

Abstracts spectrum of clinical presentations and cause very high mortality. Although aspergillosis and candidiasis are still the most common invasive mycoses in immuno-compromised hosts, but recent epidemiology suggest that the incidence of Zygomycosis has risen significantly over the past decade. We describe 2 cases of zygomycosis who unfortunately had fatal outcome despite an aggressive therapy. Case Summary 1 67-year-old man was brought to casualty, found collapsed at home. His admission tests revealed that he was in diabetic ketoacidosis (BM >60 and PH 6.9), although he was not a known diabetic. With an aggressive management of his metabolic derangement, he gradually became conscious and complained of bilateral frontal headache and complete blindness. On examination he had bilateral swollen eyes with chemosis & tenderness, complete ophthalmoplegia, blindness with no perception of light and normal optic discs. CT angiogram revealed normal brain parenchyma and cortical veins with mildly thickened mucosa of maxillary sinuses without bony erosion. CSF examination showed WCC 348 with 60% polymorphs, protein 0.7 gm, glucose 9.1(serum 18) and negative microbiology. ENT surgeons were reluctant to intervene at this stage, as there was no radiological evidence suggesting an invasive pathology. Despite an aggressive management with broadspectrum antibiotics plus AmBisome, he deteriorated rapidly and died. However a post-mortem examination confirmed the diagnosis of rhino-sino-cerebral mucormycosis. Case Summary 2 44-year-old man with Acute Lymphoblastic Leukaemia had prolonged neutropenia following first phase of induction chemotherapy. On day 22 postchemo, he developed acute painful swelling of left side of face associated with headache and dizziness. He was febrile and examination of his mouth revealed a well-demarcated necrotic ulcer with slough over the left side his hard palate. CT scan revealed marked soft tissue opacification without bony erosion of the left maxillary antrum and ethmoidal air cells, with associated pre-septal cellulitis extending down to neck. Antral biopsy revealed inflamed mucosa with necrotic slough containing large fungal hyphae and cultures grew Rhizopus arrhizus. He responded well to AmBisome plus Voriconazole combination therapy and also, he underwent repeated debridements and anterostomy after some persuation. Unfortunately he succumbed to unrelated infection later with multi-resistant Psedomonas bacteraemia. Discussion A recent study which reviewed 929 cases of zygomycosis in the English-language literature since 1885, has shown survival of 3% for untreated cases, 61% for cases treated with amphotericin B, 57% for cases treated with surgery alone, and 70% for cases treated with antifungal therapy plus surgery. This clearly reinforces the role of surgical debridement in addition to antifungal therapy in the management of these complex infections.

P 126 AN INDIAN TAKE AWAY Schaffer K, Long S, Crowe M, FitzGerald SF, Fenelon LE

e101 Dept Medical Microbiology, St.Vincent’s University Hospital, Elm Park, Dublin 4, Ireland A 38 year old male presented with a 2 day history of abdominal pain and intermittent pyrexia to the emergency department of our hospital. He had returned from India 4 weeks previously where he acquired mosquito bites on both legs. He developed cellulitis around the mosquito bites on his left ankle when he returned to Ireland for which he was prescribed a course of antibiotics by his general practitioner. On examination he had a temperature of 39.2  C and diffuse peritonism with some guarding. He was unable to stand up and complained of some nausea and vomiting. The cellulitic areas on his ankle were dry with no remarkable erythema left. Laboratory investigations showed a normal white cell count and slightly raised creatine and liver function tests. An abdominal computertomogram was performed and showed no gross abnormalities. The patient was admitted under the surgical team and an urgent laparotomy was performed. Intraoperatively free intraabdominal pus was detected especially around the duodenum. There was no faecal contamination. Stomach, liver, gallbladder, small and large bowel and appendix appeared normal. The peritoneal cavity was washed and drained. The patient was commenced on broadspectrum antibiotic therapy and intraabdominal pus samples and blood cultures were sent to the Microbiology department. Intraabdominal pus, blood cultures and a wound swab from the left ankle grew Group A Streptococcus (emm st 124) in pure culture. Lessons to be learned: 1. This is a rare case of primary Group A Streptococcus peritonitis. 2. As suggested by the emm type the patient acquired the Group A Streptococcus through an infected mosquito bite. 3. Although the patient was found to have significant amounts of free intraperitoneal pus, abdominal computertomogram failed to detect this.

P 127 A CASE OF NECROTISING FASCIITIS INVOLVING GROUP B STREPTOCOCCUS Shetty Anjali, Kubiak Elizabeth Microbiology Dept, Royal Gwent Hospital A 48-year-old woman was referred to gynaecologists, with a painful swelling on the right of her vulva. She was a diet controlled diabetic. An indurated area was noted in her right labium majus. Oral flucloxacillin and metronidazole were prescribed. She was discharged on day two with a plan for ward review. On the evening of day three, she returned with pyrexia 39-40  C, rigors and vomiting. A right vulval abscess was evident, above the line of the right groin. Her CRP and WCC had increased. Pus was drained, swabs were sent for microscopy