632 Connolly, McConnell, McGarrity

Removal of the patient from the nursing from reporting abuse of the elderly we would home to hospital allows time for appropriate caution against precipitately reaching this diag- investigation and clarification of the circums- nosis until other reasonable possibilities have tances which aroused suspicion. While not been excluded, bearing in mind that abuse may Postgrad Med J: first published as 10.1136/pgmj.71.840.632 on 1 October 1995. Downloaded from wishing to dissuade medical and nursing staff coexist with the above-mentioned conditions.

1 Pitt B. Abusing old people. BMJ 1992; 305: 968-9. 6 Mundell I. Abuse of the elderly undetected. MIMS 1992; 6 2 American Medical Association. Diagnostic and treatment May. guidelines on elder abuse and neglect. Chicago: American 7 Ogg J, Bennett G. Elder abuse in Britain. BMJ 1992; 305: Medical Association, 1992. 998-9. 3 Fisk J. Abuse of the elderly. In: Jacoby R, Oppenheimer C, 8 Kane RS, Goodwin JS. Spontaneous fractures oflong bones eds. Psychiatry in the elderly. Oxford: Oxford University in nursing home patients. Am J Med 1991; 90: 263-6. Press, 1991. 9 Ogg J, Bennett G. Community care: identifying risk factors 4 Lachs MS, Pillemer K. Abuse and neglect ofelderly persons. for elderly abuse. Geriatric Med 1991; 21: 11-9. N Engl J Med 1995; 332: 437-43. 5 Rounds L. Elder abuse and neglect: a relationship to health characteristics. J Am Acad Nurse Pract 1992; Apr-Jun: 47-52.

Spontaneous regression of pulmonary mucormycosis

Prakash Abraham, Shalini Govil, Vivi M Srivastava, Alka Ganesh

Summary The respiratory and cardiovascular systems A case of pulmonary mucormycosis with were normal. spontaneous resolution is presented. The The results ofpertinent laboratory investiga- patient had no known underlying predis- tions are given in the box. Serum potassium, posing disease. calcium, phosphorus and bicarbonate values were normal. Hepatitis B surface antigen and Keywords: pulmonary mucormycosis, Graves thyro- antibodies to HIV were negative. Stool micro- toxicosis scopy, culture and fat content were normal. Sputum was negative for acid-fast bacilli and fungus. Mucormycosis is usually a fulminant infection Chest X-ray showed two nodular opacities in

with a high mortality unless treated aggres- the midzones with cavitation, the largest http://pmj.bmj.com/ sively with amphotericin and surgical debride- measuring 4 cm (figure 1). Computed tomo- ment. It occurs primarily in patients who have graphy (CT) revealed a 3-cm soft tissue density diabetes mellitus and immunocompromised nodule in the lingula, with no evidence of states. We report an unusual case ofpulmonary cavitation or calcification. A similar 1-cm lesion mucormycosis which regressed spontaneously was also seen in the middle lobe (figure 2). without antifungal or surgical treatment. Also The patient's renal function and general unusual was the fact that the patient did not condition improved rapidly with hydration. have any described underlying predisposing Neomercazole was thought to contribute to on September 24, 2021 by guest. Protected copyright. cause for developing the infection. He had hepatic derangement, and after its withdrawal, Graves thyrotoxicosis, which has not so far been described in association with mucor- Christian Medical mycosis. College & Hospital, Vellore, India Laboratory results Department of Case report Medicine haemoglobin (g/dl) 8.9 P Abraham A 50-year-old man from North Eastern India, total white cells ( x 109/1) 26 A Ganesh who had been suffering from thyrotoxicosis neutrophils (%) 85 Department of and chronic diarrhoea intermittently for 12 blood urea (mmol/l) 71 Radiodiagnosis years, presented with jaundice, worsening diar- serum creatinine (jpmol/l) 62 S Govil serum sodium (mmol/l) 122 Department of rhoea dehydration and altered sensorium, for total bilirubin (plmol/l) 126 Pathology three weeks. He had abused alcohol in the past, direct bilirubin (pmol/l) 56 VM Srivastava but had abstained for the last five years. He had total protein (g/l) 61 no respiratory symptoms. Examination re- serum albumin (g/l) 2 Correspondence to Dr Alka vealed a dehydrated, icteric, emaciated man. serum aspartate transaminase (IU/1) 126 Ganesh, Department of The liver was palpable 2 cm below the costal serum alanine transaminase (IU/1) 75 Medicine III, Christian serum alkaline phosphatase (IU/1) 153 Medical College & Hospital, margin. Splenomegaly, ascites, and signs of random blood sugar (mmol/l) 5.4 Vellore 632004, Tamil Nadu, liver cell failure were absent. The thyroid gland India total thyroxine (nmol/l) 168.5 was diffusely enlarged. The blood pressure was free thyroxine (pmol/l) 36.2 Accepted 26 April 1995 100/70 mmHg and pulse was 88 beats/min. Spontaneous regression of pulmonary mucormycosis 633

the liver function tests reverted to normal. thyroid gland was still diffusely enlarged but Radio-iodine at a dose of 5 mCu was overt signs of thyrotoxicosis were not present.

administered for ablation of the thyroid gland. He had gained 7 kg in weight. Chest X-ray Postgrad Med J: first published as 10.1136/pgmj.71.840.632 on 1 October 1995. Downloaded from With steady improvement over 25 days of revealed complete clearing of the bilateral hospitalization, an fine-needle aspiration nodular opacities (figure 4). Follow-up CT cytology of the lung opacities was undertaken. scan of the thorax showed a residual paren- Microscopy showed necrotic material and cel- chymal fibrosis in the lingular region on the left lular debris. There were haphazardly branched side; the right lung fields were clear (figure 5). fungal hyphae, of irregular width, with rare septae, resembling Mucorales species (figure 3). After much deliberation it was decided to withhold antifungal treatment because the Mucormycosis: taxonomy patient had no respiratory symptoms, his general condition was vastly improved, and the Class - Zygomycetes Order - Mucorales lesions appeared well encapsulated. The Genera - Rhizopus patient was discharged on propranolol 40 mg - Mucor tid for control of thyrotoxic symptoms. - Absidia The patient returned for follow-up after nine - others months. He was in good general health and denied fever, cough or haemoptysis. The Mucormycosis: microscopy * hyphae- broad (10-20 pm diameter) * aseptate, right-angled branching

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Figure 3 Haphazardly branched, rarely septate hyphae of irregular width. PAP/400

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midzone lesionshaveareovdlybacerrl et 634 Abraham, Govil, Srivastava, Ganesh

Mucormycosis: events predisposing

to infection Postgrad Med J: first published as 10.1136/pgmj.71.840.632 on 1 October 1995. Downloaded from * haematologic - leukaemia, lymphoma, aplastic anaemia, myeloma * diabetes mellitus * organ transplant recipients * renal failure * immunosuppressive therapy * solid tumours * desferrioxamine therapy

Mucormycosis: clinical manifesta- tions Figure 5 Nine months later: the lingular lesion has reduced in size leaving a 1-cm hyperdense parenchymal * rhinocerebral scar * pulmonary * cutaneous * gastrointestinal * central nervous system Discussion * disseminated Although mucor are ubiquitous saprophytic fungi, normal healthy individuals are not or surgical intervention. Such a course has been usually infected. Infection with mucor occurs described before in two patients,4 one with in the setting of diabetes, leukaemia, lym- diabetes and the other with neutropenia. How- phomas, other immunocompromised states ever, such regression is very unusual. This case and desferrioxamine therapy. Pulmonary suggests that, in the absence of predisposing infection with mucor is rare, only 255 cases factors, or ifthere is rapid clinical improvement having been reported so far.' Pulmonary mucor in nutrition, and if respiratory symptoms are has been described without known predispos- not present, then pulmonary mucormycosis, ing factors in only two patients.2'3 The present can be left alone. case did not have an immunocompromised There is a theoretical possibility that radio- state, but he was malnourished after several iodine used for ablation of the thryotoxic gland months of chronic diarrhoea. Malnutrition may have been lethal to the pulmonary fungus. may have been responsible for an opportunistic Iodides are used in the treatment of sub- infection, but it has not previously been des- cutaneous phycomycosis.5 However, it is cribed as predisposing to mucor infection. highly unlikely that the isotope could have The second unusual feature in this case is the reached the lung in sufficient quantity, in the fact that there was spontaneous resolution of presence of an intact thyrotoxic thyroid gland, the mucor lesions without antifungal therapy to have any therapeutic effect. http://pmj.bmj.com/

1 Mark T, John AS, Mark PA, Sanjay SH, Stephen DT, James 4 Patrick JF, Mark JV, Richard WH. Spontaneous lysis of EL. Pulmonary mucormycosis: results of medical and sur- mycetomas after acute cavitating lung disease. Am Rev Respir gical therapy. Ann Thorac Surg 1994; 57: 1044-50. Dis 1981; 123: 336-9. 2 Record NB, Ginder DR. Pulmonary phycomycosis without 5 Utz JP, Shadomy HJ. Sporotrichosis. In: Fitzpatrick TB, obvious predisposing factors. JAMA 1976; 235: 1256-7. Eisen AZ, Wolff K, Freedberg IM, Austen KF, eds. Der- 3 Majid AA, Yii NW. Granulomatous pulmonary zygomycosis matology in general medicine, 3rd edn. New York: McGraw

in a patient without underlying illness: CT appearances and Hill Book Co, 1987; pp 2271-2. on September 24, 2021 by guest. Protected copyright. treatment by pneumonectomy. Chest 1991; 100: 560-1.