Pulmonary Basidiobolomycosis: an Unusual Presentation in a Cancer Patient: a Case Report and Mini Review of Cases in India
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Int.J.Curr.Microbiol.App.Sci (2015) 4(5): 798-805 ISSN: 2319-7706 Volume 4 Number 5 (2015) pp. 798-805 http://www.ijcmas.com Case Study Pulmonary Basidiobolomycosis: An unusual presentation in a cancer patient: A case report and mini review of cases in India Deba Dulal Biswal1, Manisa Sahu2* and Pallavi Bhaleker3 1Department of Medical Oncology, S L Raheja Hospital (A Fortis Associate) Mahim (W), Mumbai-400016, India 2Department of Microbiology, S L Raheja Hospital (A Fortis Associate) Mahim(W), Mumbai-400016, India *Corresponding author A B S T R A C T K e y w o r d s Basidiobolomycosis is an uncommon disease caused by Basidiobolus Basidiobolo- ranarum. The clinical presentation varies from localized subcutaneous mycosis, infection to widespread dissemination involving different viscera s, notably Basidio-bolus the gastrointestinal tract. Pulmonary involvement is rarer; we report a case ranarum, of pulmonary Basidiobolomycosis in a lung cancer patient. lung cancer Introduction Basidiobolo mycosis is caused by the fungus cases are from Southern part.( Sujatha S et Basidiobolus ranarum, which is a al., 2003; Chandrasekhar HR et al., 1998; zygomycetes belonging to order Prasad PV et al., 2002; Krishnan et al., Entomophthorales. (Gugnani, H. C et al., 1998) Rare dissemination with visceral 1999) This filamentous fungus is usually involvement by Basidiobolus are quoted by associated with subcutaneous zygomycosis various authors such as gastrointestinal tract, of trunk and limbs in immune competent uterus, urinary bladder and retro peritoneum. individuals (Ribes JA et al., 2000) It is an (Bigliazzi C et al., 2004; Khan ZU et al., environmental saprophyte isolated mostly 2001; Nazir Z et al., 1997; Choonhakarn C from decaying vegetation, foodstuffs, fruits, et al., 2004) Pulmonary involvement are and soil. It also inhabits the gastrointestinal exceedingly rare, only 3 cases have been tracts of reptiles, amphibians, fish, and reported so far. (Bigliazzi C et al., 2004; insectivorous bats. Basidiobolomycosis has Bittenocourt M et al., 198; Ravindran C et been reported worldwide. (Gugnani HC et al., 2010) We report a case of al., 1999). In India most of the reported basidiobolomycosis in an 798 Int.J.Curr.Microbiol.App.Sci (2015) 4(5): 798-805 immunocompromised patient, diagnosed (? Metastasis/? Fungal) & increase in soft with adenocarcinoma of lung. tissue densities apart from the malignant mass, measuring about 8.8x 8.3cm arising Case report from the left upper lobe adherent to the mediastinum. There was medistinal shifting A 59 year old patient diagnosed with to the right with multiple large necrotic adenocarcinoma of lungs few months back, lymphnodes in the perivascular, left presented to the hospital with chief paratracheal, aorto-pulmonary, left hilar, left complaints of productive cough, tracheobronchial, precarinal, subcarinal breathlessness, and fever with evening rise, region. Left sided pleural effusion (300cc) generalized weakness and inability to walk was also detected. On 4th day filamentous for two months. He was a chronic alcoholic fungi grew in slopes of Sabouraud's and and smoker. Not a known diabetic or brain heart infusion agars supplemented hypertensive and he had no past history of with chloramphenicol (0.05 tuberculosis. On examination patient was mg/ml).Colonies were initially thin, flat, conscious & oriented afebrile but cachexic, yellowish-grey to creamy grey, waxy, which mild pallor was noticed. His blood pressure later became radially folded, reverse was was 120/80 and pulse rate 96.There was no white.[Fig no.1] Lacto phenol cotton blue icterus, clubbing lymphadenopathy or pedal mount showed broad hyphae with edema. On thorough systemic examination, occasional septa and asexual spores. In rhonchii was found on left side of the chest about 12 days, we could see globose with shift of the mediastinum to the right intercalary sexual spores (zygospores) with side. Tenderness was marked over the left smooth thick walls and two prominent hypochondrium. CVS and CNS examination closely appressed beak-like appendages revealed no abnormalities. Laboratory typical of Basidiobolus ranarum.[Fig no.2] investigation showed Hb 11, TLC-7.9 with eiosinophilia & high ESR (~108). Discussion Suspecting tuberculosis sputum was sent ZN staining and AFB culture. Acid fast bacilli Over the last decade or so the clinical profile were not detected in all the three sputum of medically less important fungal samples. AFB culture was done using pathogens has taken a widely varied course, BacTalert, which was reported as no growth ranging from unusual sites, unusual clinical later. It was also sent for aerobic bacterial presentations, unusual patient profile, so on culture and fungal culture, gram stain and so forth. Basidiobolomycosis is no showed pus cells >25/low power field, exception as well. The taxonomy of the Epithelial cells <10/low power field & gram Basidiobolus group has undergone negative bacilli, but no typical respiratory considerable changes, earlier identified as B. pathogens grew. 10% KOH showed meristosporus and B. haptosporus are now occasional broad hyaline fungal filaments. regarded as synonymous with B. ranarum.( Chest X-ray PA view showed abnormal Gugnani, H. C et al., 1999) opacity in the left upper and parahillar region and fibro nodular lesions were seen The general disease manifestation involves in the right midzone suggesting mediastinal the subcutaneous tissues of the lower limbs, mass. CT scan with contrast revealed classically presenting as hardened nodules multiple pulmonary nodules in both lungs which expands locally and have with evidence of irregular septal thickening eiosinophilic infiltrations.( Gugnani, H. C et 799 Int.J.Curr.Microbiol.App.Sci (2015) 4(5): 798-805 al., 1999) Diagnosis relies on young as 6month old babies following insect histopathology demonstration of the fungal bite. (Hema P et al.,2013, Anaparthy UR et elements with fungal specific stains such as al., 2014). calcuofluor white or GMS and culture. Subcutaneous basidiobolomycosis/ No specific risk factors were identified for phycomycosis was first described in basidiobolomycosis, mostly reported in Indonesia in 1956. (Kian JL et al., 1956) previously healthy individuals except in few Subcutaneous basidiobolo mycosis has been patients who had a history of diabetes reported from all parts of India, majority mellitus Ravindran C et al., 2010, Kiran M. being from South India. (Sujatha S et Chokka et al., 2010) The Probable mode of al.,2003; Chandrasekhar HR et al., 1998; infection is trauma or insect bite(Mani Prasad PV et al.,2002; Krishnan et al., Anand et al., 2010; Hema P et al., 2013, 1998;. Naniwadekar MR et al., 2009; Rane Anaparthy UR et al., 2014). Subcutaneous S et al.,;2002; Maiti PK et al., 2004; involvement following intramuscular Ramesh V et al., 2010). However in India, injection has also been described.( Jayanth first case was reported by Mukerji et al., ST et al., 2013) 1962 in Bombay (Mumbai). (Thappa DM et al., 2003) Maiti PK et al., 2004detected 7 However the clinical spectrum of this rare cases of chronic subcutaneous fungus has expanded continuously over past phycomycosis caused by B ranarum during years, a range from chronic subcutaneous a span of 9 years from 1991 to 1999, from 9 lesion to disseminated visceral districts in and around Kolkata. Two cases involvements. Though lower extremity is of subcutaneous infections have been mostly involved, upper extremity, chest reported from western India by Girish M et even head, face, paranasal sinuses and neck al. 2011 and Sidhi B et al. 2007. regions are also involved. (Table 1) Gastrointestinal basidiobolomycosis is a Most cases are detected in children and recently described invasive fungal infection, younger individuals. (Table -1) An 11year again notably common in pediatric old girl presented with bilateral nasal block population; clinical findings may mimic and discharge due to subcutaneous malignancy. (Khan ZU et al., 2001; basidiobolomycosis from north eastern India Nemenqani D et al., 2009). with no particular predisposing factors and a more aggressive course. (Singh R et al., No case reports of GI involvement from 2008). Mani Anand et al., 2010, emphasized India so far, though in one case a 24year old that Entomophthoromycosis should be female patient presented with acute considered early when children from intestinal obstruction due to extensive endemic areas present with unusual, tumor involvement of the soft tissues of the like rapid-growing lesions of the perineum without actual affection of the subcutaneous region. intestinal mucosa (Angeline N R et al., 2011). B. ranarum has been detected as Mendiratta V et al., 2012, reported severe etiological agent of lung abscess in a 42 year cutaneous zygomycosis due to Basidiobolus old diabetic patient, the only known case of ranarum in a young infant of 9 months old, pulmonary origin from India, the precise who responded to a combination of mode of acquisition of the disease to the itraconazole and potassium iodide. viscera remains poorly understood. Basidiobolomycosis has been reported in as 800 Int.J.Curr.Microbiol.App.Sci (2015) 4(5): 798-805 Figure.1 Culture of Basidiololus ranarum on Brain heart infusion agar Slant Figure.2 Zygospores of Basidiobolus ranarum that have two closely appressed beak-like appendages 801 Int.J.Curr.Microbiol.App.Sci (2015) 4(5): 798-805 Figure.3 Asexual spores of B. ranarum As per the author the involvement of the involvement due to B haptosporus as a trachea bronchial tree could