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

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:

Histopathologically, mucormycosis may resemble:

Disease Signs and Symptoms Radiological abnormalities Histopathological abnormalities Other differentiating characters
Facial swelling and ulceration Cranial neuropathy Disturbance in ocular motility
Mucormycosis
  • The reverse halo sign on CT scan (characterized by central ground-glass opacity (GGO) which is surrounded by a partial or complete rim of consolidation)The opening <ref> tag is malformed or has a bad name is more common in patients with pulmonary mucormycosis than in those with invasive pulmonary aspergillosisThe opening <ref> tag is malformed or has a bad name
 the prognosis of pulmonary mucormycosis has not improved significantly over the last ten years, mainly because of challenges in early diagnosis and the limited activity of current antifungal agents against Mucorales[2]
Invasive aspergillosis
  • The reverse halo sign on CT scan (characterized by central ground-glass opacity (GGO) which is surrounded by a partial or complete rim of consolidation)[3] is more common in patients with pulmonary mucormycosis than in those with invasive pulmonary aspergillosis[4]
  • Airway-invasive features, such as clusters of centrilobular nodules, peribronchial consolidations, and bronchial wall thickening, are more common in patients with invasive pulmonary aspergillosis[5]
  • Microscopic observation under ultraviolet light shows that the hyphae of aspergillus have characteristic dichotomous branching, parallel walls, and numerous septa. These septa structure is clearly different from those of the mucor.
Orbital cellulitis
  • The ocular symptoms of rhino-cerebral mucormycosis (ROCM), such as facial edema, pain, and blepharoptosis, are similar to those of bacterial orbital cellulitis (BOC) soon after infection onset, therefore it maybe difficult to distinguish the two during the initial phase of infection
  • Mucormycosis is generally more commonly observed in immunocompromised patients
  • Limited eye movement was more common in patients with ROCM than in those with bacterial orbital cellulitis[6]
  • Eyelid swelling was less common in patients with ROCM than in those with bacterial orbital cellulitis due to cavernous sinus involvement[7]
  • Mucosal thickening on the paranasal sinuses is more common in ROCM than BOC[8]
Extra nodal T cell lymphoma
  • These tumors are more clearly classified as nasal-type extranodal T-cell/natural killer (T/NK) cell lymphoma and natural killer cell leukemia
  • They are characterized immunophenotypically by the expression of CD2, CD3ϵ (but not CD3 and the T-cell receptor), and CD56[9]
  • The lesion produced are destructive and involve the nasal cavity, oropharynx, upper palate, and larynx
  • Immunophenotyping shows these lesions to be lymphoid in nature
Cutaneous Anthrax
  • Cutaneous anthrax is extremely rare in developed countries
  • Usually patient history points towards the diagnosis of cutaneous anthrax
  • Patient develops a painless ulcer with vesicles, edema, and has a history of exposure to animals or animal products[10]; whereas patients with cutaneous mucormycosis are mainly debilitated (diabetics, hematological malignancies, organ transplant recepients) and present as a black necrotic eschar[11]
  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. ↑ 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.
  3. ↑ Okubo Y, Ishiwatari T, Izumi H, Sato F, Aki K, Sasai D, Ando T, Shinozaki M, Natori K, Tochigi N, Wakayama M, Hata Y, Nakayama H, Nemoto T, Shibuya K (2013). "Pathophysiological implication of reversed CT halo sign in invasive pulmonary mucormycosis: a rare case report". Diagn Pathol. 8: 82. doi:10.1186/1746-1596-8-82. PMC 3658989. PMID 23683872.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Mallon E, McKee PH (1997). "Extraordinary case report: cutaneous anthrax". Am J Dermatopathol. 19 (1): 79–82. PMID 9056659.
  11. ↑ Skiada A, Petrikkos G (2013). "Cutaneous mucormycosis". Skinmed. 11 (3): 155–9, quiz 159–60. PMID 23930354.
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