Title: Zygomycosis

{{Use dmy dates|date=December 2020}}
{{Infobox medical condition (new)
| name            = Zygomycosis
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| image           = Periorbital fungal infection known as mucormycosis, or phycomycosis PHIL 2831 lores.jpg
| caption         = Group of periorbital fungal infections including [[mucormycosis]] (shown) and [[phycomycosis]]
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'''Zygomycosis''' is the broadest term to refer to infections caused by ''bread mold [[fungus|fungi]]'' of the [[zygomycota]] phylum. However, because zygomycota has been identified as [[Polyphyly|polyphyletic]], and is not included in modern fungal classification systems, the diseases that zygomycosis can refer to are better called by their specific names: [[mucormycosis]]&lt;ref name=&quot;micol&quot;&gt;{{cite journal |first1=Carlos |last1=Toro |first2=Amalia |last2=del Palacio |first3=Carmen |last3=Álvarez |first4=José Luis |last4=Rodríguez-Peralto |first5=Esperanza |last5=Carabias |first6=Soledad |last6=Cuétara |first7=Yolanda |last7=Carpintero |first8=César |last8=Gómez |title=Zigomicosis cutánea por ''Rhizopus arrhizus'' en herida quirúrgica |trans-title=Cutaneous zygomycosis caused by ''Rhizopus arrhizus'' in a surgical wound |language=es |journal=Revista Iberoamericana de Micología |pmid=17655419 |url=http://www.reviberoammicol.com/pubmed_linkout.php?15p94 |year=1998 |volume=15 |issue=2 |pages=94–6}}&lt;/ref&gt; (after [[Mucorales]]), [[phycomycosis]]&lt;ref name=&quot;maxilla&quot;/&gt; (after [[Phycomycetes]]) and [[basidiobolomycosis]] (after ''[[Basidiobolus]]'').&lt;ref&gt;{{cite journal |pmid=21033182 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4832a3.htm |title=Gastrointestinal Basidiobolomycosis — Arizona, 1994–1999 |year=1999 |author1=Centers for Disease Control and Prevention |volume=48 |issue=32 |pages=710–3 |journal=Morbidity and Mortality Weekly Report}}&lt;/ref&gt; These rare yet serious and potentially life-threatening fungal infections usually affect the [[face]] or [[oropharyngeal|oropharyngeal (nose and mouth)]] cavity.&lt;ref name=&quot;Emedicine&quot;&gt;{{cite web |url=http://www.emedicine.com/med/topic1513.htm |title= Mucormycosis |author1=Nancy F Crum-Cianflone |author2=MD MPH |publisher=eMedicine|access-date=2008-05-19 }}&lt;/ref&gt; Zygomycosis type infections are most often caused by common fungi found in soil and decaying vegetation. While most individuals are exposed to the fungi on a regular basis, those with immune disorders ([[immunocompromised]]) are more prone to fungal infection.&lt;ref name=&quot;maxilla&quot;/&gt;&lt;ref name=&quot;medplus&quot;&gt;{{MedlinePlus|000649|Mucormycosis}}&lt;/ref&gt;&lt;ref name=&quot;Ettinger_1995&quot;&gt;{{cite book |last1=Ettinger |first1=Stephen J. |last2=Feldman |first2=Edward C. |title=Textbook of Veterinary Internal Medicine |edition=4th |publisher=W.B. Saunders Company |year=1995 |isbn=0-7216-6795-3}}{{Page needed|date=September 2011}}&lt;/ref&gt; These types of infections are also common after natural disasters, such as tornadoes or earthquakes, where people have open wounds that have become filled with soil or vegetative matter.&lt;ref&gt;{{cite news |first1=Bill |last1=Draper |first2=Jim |last2=Suhr |agency=Associated Press |date=11 June 2011 |title=Survivors of Joplin tornado develop rare infection |url=http://cmf-cdn.seattlepi.com/news/article/Aggressive-fungus-strikes-Joplin-tornado-victims-1418689.php |work=[[Seattle Post-Intelligencer]] }}{{Dead link|date=October 2022 |bot=InternetArchiveBot |fix-attempted=yes }}&lt;/ref&gt;

The condition may affect the [[gastrointestinal tract]] or the [[skin]], often beginning in the nose and paranasal [[sinuses]]. It is one of the most rapidly spreading fungal infections in humans. Treatment consists of prompt and intensive [[antifungal drug]] therapy and [[surgery]] to remove the infected tissue.

== Symptoms and signs==
In the primary cutaneous form, the lesions are usually painful and necrotic, with black [[eschar]], accompanied by a fever. Patients will usually present with a history of poorly controlled diabetes or malignancy.&lt;ref&gt;{{cite journal |vauthors=Rodríguez-Lobato E, Ramírez-Hobak L, Aquino-Matus JE, Ramírez-Hinojosa JP, Lozano-Fernández VH, Xicohtencatl-Cortes J, Hernández-Castro R, Arenas R |title=Primary Cutaneous Mucormycosis Caused by ''Rhizopus oryzae'': A Case Report and Review of Literature |journal=Mycopathologia |volume=182 |issue=3-4 |pages=387–392 |date=April 2017 |pmid=27807669 |doi=10.1007/s11046-016-0084-6 }}&lt;/ref&gt; Myocutaneous infections may lead to amputation. Pulmonary tract infections seen with lung transplant patients, who are at high risk for fatal invasive mycoses.&lt;ref&gt;{{cite journal |vauthors=Mattner F, Weissbrodt H, Strueber M |title=Two case reports: fatal ''Absidia corymbifera'' pulmonary tract infection in the first postoperative phase of a lung transplant patient receiving voriconazole prophylaxis, and transient bronchial ''Absidia corymbifera'' colonization in a lung transplant patient |journal=Scand J Infect Dis |volume=36 |issue=4 |pages=312–4 |date=2004 |pmid=15198193 |doi=10.1080/00365540410019408 }}&lt;/ref&gt; Rhinocerebral infection is characterized by paranasal swelling with necrotic tissues. Patient may have hemorrhagic exudates (tissue fluid from lesions tinged with blood) from the nose and eyes as the fungi penetrate through blood vessels and other anatomical structures.&lt;ref name=&quot;:0&quot; /&gt;

==Causes==
[[Image:zygomycosis.jpg|thumb|right|[[Micrograph]] showing a zygomycetes infection]]
Pathogenic zygomycosis is caused by species in two orders: [[Mucorales]] or [[Entomophthorales]], with the former causing far more disease than the latter.&lt;ref name=&quot;pmid10756000&quot;&gt;{{cite journal |doi=10.1128/CMR.13.2.236 |title=Zygomycetes in Human Disease |year=2000 |last1=Ribes |first1=J. A. |last2=Vanover-Sams |first2=C. L. |last3=Baker |first3=D. J. |journal=Clinical Microbiology Reviews |volume=13 |issue=2 |pages=236–301 |pmid=10756000 |pmc=100153}}&lt;/ref&gt; These diseases are known as &quot;mucormycosis&quot; and &quot;entomophthoramycosis&quot;, respectively.&lt;ref name=&quot;pmid14748801&quot;&gt;{{cite journal |pages=31–47 |doi=10.1111/j.1470-9465.2004.00843.x |title=Mucormycosis and entomophthoramycosis: A review of the clinical manifestations, diagnosis and treatment |year=2004 |last1=Prabhu |first1=R. M. |last2=Patel |first2=R. |journal=Clinical Microbiology and Infection |volume=10 |pmid=14748801|doi-access=free }}&lt;/ref&gt;
* Order [[Mucorales]] (mucormycosis)
** Family [[Mucoraceae]]
*** ''[[Absidia]]'' (''[[Absidia corymbifera]]'')
*** ''[[Apophysomyces]]'' (''[[Apophysomyces elegans]]'' and ''{{interlanguage link|Apophysomyces trapeziformis|ceb|Apophysomyces trapeziformis}}'')
*** ''[[Mucor]]'' (''[[Mucor indicus]]'')
*** ''[[Rhizomucor]]'' (''[[Rhizomucor pusillus]]'')
*** ''[[Rhizopus]]'' (''[[Rhizopus oryzae]]'')
** Family [[Cunninghamellaceae]]
*** ''[[Cunninghamella]]'' (''[[Cunninghamella bertholletiae]]'')
** Family [[Thamnidiaceae]]
*** ''[[Cokeromyces]]'' (''[[Cokeromyces recurvatus]]'')
** Family [[Saksenaeaceae]]
*** ''[[Saksenaea]]'' (''[[Saksenaea vasiformis]]'')
** Family [[Syncephalastraceae]]
*** ''[[Syncephalastrum]]'' (''[[Syncephalastrum racemosum]]'')
* Order [[Entomophthorales]] ([[entomophthoramycosis]])
** Family [[Basidiobolaceae]]
*** ''[[Basidiobolus]]'' (''[[Basidiobolus ranarum]]'')
** Family [[Ancylistaceae]]
*** ''[[Conidiobolus]]'' (''[[Conidiobolus coronatus]]/[[Conidiobolus incongruus]]'')

== Diagnosis ==
Diagnosis is done with [[potassium hydroxide]] (KOH) preparation in tissue. On light microscopy, there will be broad, ribbon-like [[septate hyphae]] with 90 degree angles on branches.&lt;ref name=&quot;:0&quot;&gt;{{Cite book|last=Moscatello|first=Kim|title=USMLE Step 1: Immunology and Microbiology Lecture Notes|publisher=Kaplan Publishing|year=2013|isbn=978-1625232557|location=Chicago|pages=430–1}}&lt;/ref&gt; KOH wet mount of the black eschar will show fungal [[aseptate hyphae]] with right angle branching. [[Periodic acid–Schiff stain|Periodic Acid Schiff]] (PAS) staining will reveal similar broad hyphae in the dermis and cutis. Fungal culture can also confirm the organism.&lt;ref name=&quot;:2&quot;&gt;{{cite journal |vauthors=Li H, Hwang SK, Zhou C, Du J, Zhang J |title=Gangrenous cutaneous mucormycosis caused by ''Rhizopus oryzae'': a case report and review of primary cutaneous mucormycosis in China over Past 20 years |journal=Mycopathologia |volume=176 |issue=1-2 |pages=123–8 |date=August 2013 |pmid=23615822 |doi=10.1007/s11046-013-9654-z }}&lt;/ref&gt; Diagnosis remains difficult due to the lack of laboratory tests as mortality remains high. In 2005, a multiplex PCR test was able to identify five species of ''[[Rhizopus]]'' and may prove useful as a screening method for visceral mucormycosis in the future.&lt;ref name=&quot;:1&quot;&gt;{{cite journal |vauthors=Nagao K, Ota T, Tanikawa A, Takae Y, Mori T, Udagawa S, Nishikawa T |title=Genetic identification and detection of human pathogenic Rhizopus species, a major mucormycosis agent, by multiplex PCR based on internal transcribed spacer region of rRNA gene |journal=J Dermatol Sci |volume=39 |issue=1 |pages=23–31 |date=July 2005 |pmid=15978416 |doi=10.1016/j.jdermsci.2005.01.010 }}&lt;/ref&gt;

The clinical approach to diagnosis includes radiologic, where more than ten nodules and pleural effusion are associated to pulmonary forms of the disease. In CT, a reverse halo sign is noted. Direct microscopy and histopathology, and cultures remain the gold standards for diagnoses.&lt;ref name=&quot;ReferenceA&quot;&gt;{{cite journal |vauthors=Skiada A, Lass-Floerl C, Klimko N, Ibrahim A, Roilides E, Petrikkos G |title=Challenges in the diagnosis and treatment of mucormycosis |journal=Med Mycol |volume=56 |issue=suppl_1 |pages=93–101 |date=April 2018 |pmid=29538730 |pmc=6251532 |doi=10.1093/mmy/myx101 }}&lt;/ref&gt; ''Zygomycophyta'' share close clinical and radiological features to Aspergillosis. Invasive procedures such as bronchial endoscopy and lung biopsy may be necessary to confirm pulmonary diagnosis are no validated indirect tests are available. Quantitative polymerase chain reaction to detect serum DNA of the pathogen shows promise.&lt;ref&gt;{{cite journal |vauthors=Danion F, Aguilar C, Catherinot E, Alanio A, DeWolf S, Lortholary O, Lanternier F |title=Mucormycosis: New Developments into a Persistently Devastating Infection |journal=Semin Respir Crit Care Med |volume=36 |issue=5 |pages=692–705 |date=October 2015 |pmid=26398536 |doi=10.1055/s-0035-1562896 }}&lt;/ref&gt;

== Treatment ==
The condition may affect the [[gastrointestinal tract]] or the [[skin]]. In non-trauma cases, it usually begins in the nose and paranasal [[sinuses]] and is one of the most rapidly spreading fungal infections in humans.&lt;ref name=&quot;maxilla&quot;&gt;{{cite journal |last1=Auluck |first1=Ajit |title=Maxillary necrosis by mucormycosis. a case report and literature review |journal=Medicina Oral Patologia Oral y Cirugia Bucal |volume=12 |issue=5 |pages=E360–4 |year=2007 |pmid=17767099 |url=http://www.medicinaoral.com/medoralfree01/v12i5/medoralv12i5p360.pdf}}&lt;/ref&gt; Common symptoms include [[thrombosis]] and tissue [[necrosis]].&lt;ref name=&quot;cmrasm&quot;&gt;{{cite journal |pages=556–69 |doi=10.1128/CMR.18.3.556-569.2005 |title=Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management |year=2005 |last1=Spellberg |first1=B. |last2=Edwards |first2=J. |last3=Ibrahim |first3=A. |journal=Clinical Microbiology Reviews |volume=18 |issue=3 |pmid=16020690 |pmc=1195964}}&lt;/ref&gt;

Due to the organisms' rapid growth and invasion, zygomycosis presents with a high fatality rate. Treatment must begin immediately with debridement of the necrotic tissue plus [[amphotericin B]].&lt;ref name=&quot;:0&quot; /&gt; Complete excision of the infectious tissue may be required as suspected dead tissue must be excised aggressively.&lt;ref name=&quot;:2&quot; /&gt;&lt;ref name=&quot;Spellberg_2009&quot;&gt;{{cite journal |doi=10.1086/599105 |title=Recent Advances in the Management of Mucormycosis: From Bench to Bedside |year=2009 |author-link3=Dimitrios Kontoyiannis |last1=Spellberg |first1=Brad |last2=Walsh |first2=Thomas J. |last3=Kontoyiannis |first3=Dimitrios P. |last4=Edwards |first4=Jr. |last5=Ibrahim |first5=Ashraf S. |journal=Clinical Infectious Diseases |volume=48 |issue=12 |pages=1743–51 |pmid=19435437 |pmc=2809216}}&lt;/ref&gt;&lt;ref name=&quot;Grooters_2003&quot;&gt;{{cite journal |doi=10.1016/S0195-5616(03)00034-2 |title=Pythiosis, lagenidiosis, and zygomycosis in small animals |year=2003 |last1=Grooters |first1=A |journal=Veterinary Clinics of North America: Small Animal Practice |volume=33 |issue=4 |pages=695–720 |pmid=12910739}}&lt;/ref&gt; In a documented case, conservative surgical drainage and intravenous amphotericin B in an insulin-dependent diabetic was proven effective in sino-orbital infection.&lt;ref&gt;{{cite journal |vauthors=Rosenberger RS, West BC, King JW |title=Survival from sino-orbital mucormycosis due to ''Rhizopus rhizopodiformis'' |journal=Am J Med Sci |volume=286 |issue=3 |pages=25–30 |date=1983 |pmid=6356916 |doi=10.1097/00000441-198311000-00004 }}&lt;/ref&gt; The prognosis varies vastly depending upon an individual patient's circumstances.&lt;ref name=&quot;cmrasm&quot;/&gt;

==Epidemiology==
Zygomycosis has been found in survivors of the [[2004 Indian Ocean earthquake and tsunami]] and in survivors of the [[2011 Joplin tornado|2011 Joplin, Missouri tornado]].&lt;ref&gt;{{cite news |title=Joplin toll rises to 151; some suffer from fungus |url=http://www.physorg.com/news/2011-06-aggressive-fungus-joplin-tornado-victims.html |agency=Associated Press |date=10 June 2011 |via=Medical Xpress}}&lt;/ref&gt;

==Other animals==
The term [[oomycosis]] is used to describe [[oomycete]] infections.&lt;ref name=&quot;urlMerck Veterinary Manual&quot;&gt;{{cite web |url=http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/51112.htm |url-status=dead |archive-url=https://web.archive.org/web/20090313235013if_/http://www.merckvetmanual.com:80/mvm/index.jsp?cfile=htm/bc/51112.htm |archive-date=2009-03-13 |title=Merck Veterinary Manual |access-date=2025-03-23}}{{cbignore}}&lt;/ref&gt; These are more common in animals, notably [[dog]]s and [[horse]]s. These are [[heterokont]]s, not true fungi. Types include [[pythiosis]] (caused by ''[[Pythium insidiosum]]'') and [[lagenidiosis]].

Zygomycosis has been described in a [[cat]], where fungal infection of the [[Tracheobronchial tree|tracheobronchus]] led to respiratory disease requiring [[Euthanasia (animal)|euthanasia]].&lt;ref&gt;{{cite journal |pmid=21158233 |year=2010 |last1=Snyder |first1=Katherine D. |last2=Spaulding |first2=Kathy |last3=Edwards |first3=John |title=Imaging diagnosis—tracheobronchial zygomycosis in a cat |volume=51 |issue=6 |pages=617–20 |journal=Veterinary Radiology &amp; Ultrasound |doi=10.1111/j.1740-8261.2010.01720.x}}&lt;/ref&gt;

==References==
{{Reflist}}

== External links ==
{{Medical resources
|  DiseasesDB      = 31329
|  ICD10           = {{ICD10|B|46||b|35}}
|  ICD9            = {{ICD9|117.7}}
|  ICDO            =
|  OMIM            =
|  MedlinePlus     = 000649
|  eMedicineSubj   = med
|  eMedicineTopic  = 1513
|  eMedicine_mult  = {{eMedicine2|med|2026}} {{eMedicine2|oph|225}} {{eMedicine2|ped|1488}}
|  MeshID          = D020096
}}
{{Mycoses}}

[[Category:Animal fungal diseases]]
[[Category:Dog diseases]]
[[Category:Horse diseases]]
[[Category:Mycosis-related cutaneous conditions]]
[[Category:Parasitic fungi]]
[[Category:Sheep and goat diseases]]