Mucormycosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Mucormycosis can be difficult to diagnose and a high degree of clinical suspicion is required. Mucormycosis should be differentiated from diseases like invasive aspergillosis, orbital cellulitis, extra nodal T cell lymphoma and cutaneous anthrax. Patient history is an important part of the diagnosis and aids in ruling out other differentials. Other features which help differentiate conditions with similar presentations are radiological and histopathological appearance.

Differential diagnosis

Mucormycosis must be differentiated from other conditions with similar presentation. Invasive fungal disease should be considered in any immunocompromised patient presenting with a new cranial neuropathy or ocular motility abnormality[1] for example, invasive aspergillosis. Other differential diagnoses which may involve progressive facial swelling, ulceration and destruction and resemble mucormycosis include orbital cellulitis, extra nodal T cell lymphoma and cutaneous anthrax. Histopathologically mucormycosis may resemble pancreatic and gouty panniculitis.

Disease General features Signs and Symptoms Radiological abnormalities Histopathological abnormalities Other differentiating characters
Facial/Sinus swelling and ulceration Cranial neuropathy Disturbance in ocular motility
Mucormycosis
  • +

(Mucosal thickening on the paranasal sinuses is more common in rhinocerebral mucormycosis(ROCM) than bacterial orbital cellulitis(BOC)[2]

  • +

(Specially if there is invasion of the cavernous sinus)

  • +

(Limited eye movement is more common in patients with rhino-cerebral mucormycosis (ROCM) than in those with bacterial orbital cellulitis)[3]

  • Nonpigmented, wide (5- to 20-μm), thin-walled, ribbon-like hyphae with few septations (pauciseptate) and right-angle branching[4]
  • In lesions exposed to air, thick-walled spherical structures can form at the ends of the hyphae
  • Fungal elements invading the blood vessel wall or inside their lumen
Invasive aspergillosis
  • +
  • +
  • +

(There may be painful ophthalmoplegia if there is invasion of the cavernous sinus)[7]

Orbital cellulitis
  • +
  • +

(The ocular symptoms of bacterial orbital cellulitis (BOC) , such as facial edema, pain, and blepharoptosis, are similar to those of rhino-cerebral mucormycosis (ROCM) soon after infection onset, therefore it maybe difficult to distinguish the two during the initial phase of infection.

Eye lid swelling is more common in BOC than ROCM)[10]

Extra nodal T cell lymphoma
  • +

(Primary CNS NK/Tcell lymphoma of the nasal type)

  • +/-
Cutaneous Anthrax
  • +

References

  1. Trief D, Gray ST, Jakobiec FA, Durand ML, Fay A, Freitag SK, Lee NG, Lefebvre DR, Holbrook E, Bleier B, Sadow P, Rashid A, Chhabra N, Yoon MK (2016). "Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus". Br J Ophthalmol. 100 (2): 184–8. doi:10.1136/bjophthalmol-2015-306945. PMID 26112869.
  2. Son JH, Lim HB, Lee SH, Yang JW, Lee SB (2016). "Early Differential Diagnosis of Rhino-Orbito-Cerebral Mucormycosis and Bacterial Orbital Cellulitis: Based on Computed Tomography Findings". PLoS ONE. 11 (8): e0160897. doi:10.1371/journal.pone.0160897. PMC 4976984. PMID 27501044.
  3. Son JH, Lim HB, Lee SH, Yang JW, Lee SB (2016). "Early Differential Diagnosis of Rhino-Orbito-Cerebral Mucormycosis and Bacterial Orbital Cellulitis: Based on Computed Tomography Findings". PLoS ONE. 11 (8): e0160897. doi:10.1371/journal.pone.0160897. PMC 4976984. PMID 27501044.
  4. Guarner J, Brandt ME (2011). "Histopathologic diagnosis of fungal infections in the 21st century". Clin. Microbiol. Rev. 24 (2): 247–80. doi:10.1128/CMR.00053-10. PMC 3122495. PMID 21482725.
  5. Trief D, Gray ST, Jakobiec FA, Durand ML, Fay A, Freitag SK, Lee NG, Lefebvre DR, Holbrook E, Bleier B, Sadow P, Rashid A, Chhabra N, Yoon MK (2016). "Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus". Br J Ophthalmol. 100 (2): 184–8. doi:10.1136/bjophthalmol-2015-306945. PMID 26112869.
  6. Hamilos G, Samonis G, Kontoyiannis DP (2011). "Pulmonary mucormycosis". Semin Respir Crit Care Med. 32 (6): 693–702. doi:10.1055/s-0031-1295717. PMID 22167397.
  7. Siraj CA, Krishnan J, Nair RR, Girija AS (2005). "Invasive aspergillosis producing painful ophthalmoplegia". J Assoc Physicians India. 53: 901–2. PMID 16459537.
  8. Jung J, Kim MY, Lee HJ, Park YS, Lee SO, Choi SH, Kim YS, Woo JH, Kim SH (2015). "Comparison of computed tomographic findings in pulmonary mucormycosis and invasive pulmonary aspergillosis". Clin. Microbiol. Infect. 21 (7): 684.e11–8. doi:10.1016/j.cmi.2015.03.019. PMID 25882362.
  9. Chaudhry IA, Al-Rashed W, Arat YO (2012). "The hot orbit: orbital cellulitis". Middle East Afr J Ophthalmol. 19 (1): 34–42. doi:10.4103/0974-9233.92114. PMC 3277022. PMID 22346113.
  10. Son JH, Lim HB, Lee SH, Yang JW, Lee SB (2016). "Early Differential Diagnosis of Rhino-Orbito-Cerebral Mucormycosis and Bacterial Orbital Cellulitis: Based on Computed Tomography Findings". PLoS ONE. 11 (8): e0160897. doi:10.1371/journal.pone.0160897. PMC 4976984. PMID 27501044.
  11. Zhang Y, Wang T, Liu GL, Li J, Gao SQ, Wan L (2016). "Mucormycosis or extranodal natural killer/T cell lymphoma, similar symptoms but different diagnosis". J Mycol Med. 26 (3): 277–82. doi:10.1016/j.mycmed.2016.04.005. PMID 27178138.
  12. Prajapati HJ, Vincentelli C, Hwang SN, Voloschin A, Crocker I, Dehkharghani S (2014). "Primary CNS natural killer/T-cell lymphoma of the nasal type presenting in a woman: case report and review of the literature". J. Clin. Oncol. 32 (8): e26–9. doi:10.1200/JCO.2012.47.6796. PMID 24419127.
  13. Mallon E, McKee PH (1997). "Extraordinary case report: cutaneous anthrax". Am J Dermatopathol. 19 (1): 79–82. PMID 9056659.
  14. Skiada A, Petrikkos G (2013). "Cutaneous mucormycosis". Skinmed. 11 (3): 155–9, quiz 159–60. PMID 23930354.

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