Mucormycosis in patients with haematological malignancies: a retrospective clinical study of 37 cases. GIMEMA Infection Program (Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto)

Disseminated Cunninghamella bertholletiae infection with septic pulmonary embolism after allogeneic bone marrow transplantation

Mucormycosis in immunocompromised patients is often reported. We report a patient who developed non-thrombotic pulmonary embolism due to Cunninghamella bertholletiae after allogeneic stem cell transplantation.

Successful treatment of disseminated mucormycosis in a neutropenic patient with T-cell acute lymphoblastic leukaemia

Mucormycosis is a rare angioinvasive fungal infection, more commonly seen in immunosuppressed patients, with reported mortality rates of 95% in disseminated disease. We present a case report of a patient with T-cell acute lymphoblastic leukaemia who developed disseminated infection with mucormycosis (involving the pancreas, left occipital lobe, right lower lobe of lung, appendix and right kidney) after having completed induction and consolidation chemotherapy. Growth of Lichtheimia corymbifera was initially isolated following a right pleural tap with fungal elements identified repeatedly on subsequent pathology specimens. Following radical surgical debridement and concurrent treatment with combination antifungal therapy, the patient survived. This case demonstrates that aggressive multisite surgical de-bulking of disseminated fungal foci, in conjunction with combination antifungal therapy and reversal of immunosuppression, can result in survival despite the grave prognosis associated with disseminated mucormycosis.

An autopsy case of pulmonary fissure induced by zygomycosis

For immunodeficient patients, fungi are life-threatening pathogens. In this paper, we present an autopsy case of combined zygomycosis and aspergillosis. A female in her 70s on chronic hemodialysis was admitted to a hospital suffering bloody sputum, dyspnea, and fever, probably due to perinuclear anti-neutrophil cytoplasmic antibody-related vasculitis. Antibiotics were administered and immunosuppressive therapy was started, resulting in an improvement in her condition. Pneumonia later developed, followed by pulmonary bleeding and intractable pneumothorax from which she ultimately died. On autopsy, the upper lobe of the left lung was found to have hemorrhagic necrosis and showed a large longitudinal fissure. Microscopically, Zygomycota were observed in both the lungs and heart, while Aspergillus was found in the middle lobe of the right lung. Zygomycosis, which usually has a poor prognosis, is assumed to have induced hemorrhagic infarction of the lungs, inducing pulmonary bleeding and necrosis, despite the use of lipid formulations of amphotericin B, which are effective medicines against Zygomycota.

Risk factors for early mortality in haematological malignancy patients with pulmonary mucormycosis

Pulmonary mucormycosis (PM) is a life-threatening opportunistic mycosis with a variable clinical evolution and few prognostic markers for outcome assessment. Several clinical risk factors for poor outcome present at the diagnosis of PM were analyzed in 75 consecutive hematology patients from 2000-2012. Significant variables (P < 0.1) were entered into a multivariate Cox-proportional hazard regression model adjusting for baseline APACHE II to identify independent risk factors for mortality within 28 days. Twenty-eight of 75 patients died within 4-week follow up. A lymphocyte count < 100/mm³ at the time of diagnosis (adjusted hazard ratio 4.0, 1.7-9.4, P = 0.01) and high level of lactate dehydrogenase (AHR 3.7, 1.3-10.2, P = 0.015) were independent predictors along with APACHE II score for 28-day mortality. A weighted risk score based on these 3 baseline variables accurately identified non-surviving patients at 28 days (area under the receiver-operator curve of 0.87, 0.77-0.93, P < 0.001). A risk score > 22 was associated with 8-fold high rates of mortality (P < 0.0001) within 28 days of diagnosis and median survival of 7 days versus ≥28 days in patients with risk scores ≤22. We found that APACHE II score, severe lymphocytopenia and high LDH levels at the time of PM diagnosis were independent markers for rapid disease progression and death.

Successful surgical and medical treatment of rhizopus osteomyelitis following hematopoietic cell transplantation

Mucormycosis has been reported in otherwise healthy individuals; however, it is primarily seen in immunocompromised patients, such as those with diabetes mellitus, malignancy, or chronic graft-versus-host disease, and has a high mortality rate. Because most cases of mucormycosis are associated with contiguous rhinocerebral infection, only 5 cases of isolated musculoskeletal Rhizopus infection have been reported in the literature. One patient underwent hematopoietic cell transplant, which resulted in a fatal outcome.This article describes the successful treatment of isolated Rhizopus osteomyelitis in a patient who underwent hematopoietic cell transplant using a combined surgical and medical approach. A 33-year-old woman with pre-B cell acute lymphoblastic leukemia underwent hematopoietic cell transplant with few complications but developed chronic graft-versus-host disease 8 months posttransplant. She was treated with high-dose steroids for 6 weeks before she was admitted for severe right tibial pain in the absence of trauma. Early detection, aggressive therapies, and a multidisciplinary surgical and medical team allowed for the microbiologically confirmed resolution of the infection. Treatment included multiagent antimicrobial therapy with amphotericin B, daptomycin, and ertapenem. Several surgical irrigation and debridement procedures were also performed, with the eventual placement of amphotericin-impregnated polymethylmethacrylate cement beads and small fragment titanium screws. The patient continued taking postoperative antifungal treatment for 7 months after discharge. Six months following the discontinuation of antifungal therapy, the team's multidisciplinary approach achieved a continued resolution of the patient's infection and a return to a fully ambulatory and radiographically proven recovery without limb loss.

Endonasal treatment of acute invasive fungal rhinosinusitis in immunocompromised pediatric hematology-oncology patients

OBJECTIVES

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive fungal infection in immunocompromised patients with high mortality rates. The aim of this study is to present our experiences on endonasal treatment in immunocompromised pediatric hematology-oncology patients with AIFR.

METHODS

Thirteen pediatric hematology-oncology patients treated for AIFR between March 2006 and December 2011 were analyzed retrospectively. We reviewed the following data for all patients: age, gender, predisposing disease, initial symptoms, pathological diagnosis, microbiological results, laboratory findings, surgical procedure, number of operations and treatment outcomes.

RESULTS

Nine of 13 patients with lesions confined to sinonasal cavity were operated with endoscopic approach. Open surgery was performed in four patients, three of them had palatal and buccal lesions and one had facial skin involvement. Endoscopic approach was also used for sinonasal lesions of these four patients. A total of 7 patients died: 4 patients with progression of the underlying disease, 2 patients with sepsis and 1 patient due to renal failure. Survival rate in surgically treated patients was found 46% (6/13 patients).

CONCLUSIONS

Endonasal endoscopic approach is both feasible and efficient technique, also enables excellent local control with less morbidity compared to open surgery. This approach is suitable for patients who are diagnosed in the early stages of AIFR and also presents a less traumatic option for patients with poor health status. Open surgical procedure should be preferred in patients with disease extending out of the sinonasal cavity.

Diagnosis and treatment of mucormycosis in patients with hematological malignancies: guidelines from the 3rd European Conference on Infections in Leukemia (ECIL 3)

Mucormycosis is an emerging cause of infectious morbidity and mortality in patients with hematologic malignancies. However, there are no recommendations to guide diagnosis and management. The European Conference on Infections in Leukemia assigned experts in hematology and infectious diseases to develop evidence-based recommendations for the diagnosis and treatment of mucormycosis. The guidelines were developed using the evidence criteria set forth by the American Infectious Diseases Society and the key recommendations are summarized here. In the absence of validated biomarkers, the diagnosis of mucormycosis relies on histology and/or detection of the organism by culture from involved sites with identification of the isolate at the species level (no grading). Antifungal chemotherapy, control of the underlying predisposing condition, and surgery are the cornerstones of management (level A II). Options for first-line chemotherapy of mucormycosis include liposomal amphotericin B and amphotericin B lipid complex (level B II). Posaconazole and combination therapy of liposomal amphotericin B or amphotericin B lipid complex with caspofungin are the options for second line-treatment (level B II). Surgery is recommended for rhinocerebral and skin and soft tissue disease (level A II). Reversal of underlying risk factors (diabetes control, reversal of neutropenia, discontinuation/taper of glucocorticosteroids, reduction of immunosuppressants, discontinuation of deferroxamine) is important in the treatment of mucormycosis (level A II). The duration of antifungal chemotherapy is not defined but guided by the resolution of all associated symptoms and findings (no grading). Maintenance therapy/secondary prophylaxis must be considered in persistently immunocompromised patients (no grading).

Epidemiology and clinical manifestations of mucormycosis

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. Mucormycosis has emerged as the third most common invasive mycosis in order of importance after candidiasis and aspergillosis in patients with hematological and allogeneic stem cell transplantation. Mucormycosis also remains a threat in patients with diabetes mellitus in the Western world. Furthermore, this disease is increasingly recognized in recently developed countries, such as India, mainly in patients with uncontrolled diabetes or trauma. Epidemiological data on this type of mycosis are scant. Therefore, our ability to determine the burden of disease is limited. Based on anatomic localization, mucormycosis can be classified as one of 6 forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon presentations. The underlying conditions can influence clinical presentation and outcome. This review describes the emerging epidemiology and the clinical manifestations of mucormycosis.

Mucormycosis of the head and neck

INTRODUCTION

Mucormycosis of the head and neck is a rare disease increasingly occurring in immunocompromised patients. We report on two cases with different outcomes.

CASE REPORTS

A 63-year-old female presented with a recently developed deformation of her right cheek and nose combined with a loosening of the teeth. Further examination revealed mucormycosis of the maxilla. Hemimaxillectomy and secondary bony reconstruction with oral rehabilitation were performed. The second patient was a 54-year-old male who suffered from multiple myeloma. After receiving an allogeneic haematopoietic stem cell transplant, he developed a necrotizing infection of the right midface. Histopathological investigation confirmed the diagnosis of mucormycosis. The patient died one day after radical surgical resection.

DISCUSSION

These two cases demonstrate the variability of mucormycosis. Although slow progression of the disease is possible, a high level of attentiveness and expedient treatment are necessary due to the high risk of a devastating course.

Hepatic mucormycosis in a patient of acute lymphoblastic leukemia: a case report with literature review

Mucormycosis is an invasive opportunistic fungal infection associated with a high mortality rate, and normally occurs in immunocompromised patients. It can be encountered during neutropenia following chemotherapy in acute leukemia patients. The common sites involved are rhinocerebral, pulmonary, gastrointestinal and spleen. Hepatic involvement has been reported rarely. We hereby report a case of acute lymphoblastic leukemia who while on chemotherapy developed hepatic mucormycosis and was managed successfully despite its treatment being quite challenging, especially in the context of surgery in a neutropenic sick patient.

Uncommon mold infections in hematological patients: epidemiology, diagnosis and treatment

Invasive fungal diseases continue to be an important cause of morbidity and mortality in immunosuppressed patients. This is of particular interest, since the progress we made in the treatment of underlying malignancies has led to an increase of the number of persons 'at high risk'. During the last few years, several changes in clinical practice in hematology (new immunosuppressants, hematopoietic stem cell transplants) have influenced the epidemiology of invasive fungal diseases; in particular, cases due to some uncommon etiologic agents are being increasingly reported, making it even more urgent to reconsider differential diagnoses in high-risk patients. A better understanding of epidemiology, risk factors and prognosis appears to be crucial to analyze prevention and diagnostic strategies, as well as to guarantee an early and adequate treatment.

Immunotherapy of infections caused by rare filamentous fungi

Invasive fungal infections caused by rare filamentous fungi constitute a significant cause of morbidity and mortality in patients with defective immune responses. Despite the advent of new antifungal agents, the problem is escalating as the number of susceptible hosts increases and virulent, more resistant fungal strains emerge. There is evidence that reconstitution of the host immune function is a major contributor to the resolution of these infections. Therapeutic modalities aimed at increasing phagocyte numbers, such as granulocyte transfusions, stimulating the immune response, such as administration of haematopoietic growth factors and other proinflammatory cytokines, or indirectly augmenting immune function have shown promising results in the preclinical setting. Because of the rarity of the infections, multicentre clinical trials are needed to demonstrate the efficacy and safety of the new immunomodulating approaches.

Pulmonary venous invasion, determined by chest computed tomographic scan, as a potential early indicator of zygomycosis infection: a case series

Zygomycosis is a life-threatening fungal infection, and its successful treatment requires early diagnosis. To establish radiologic and clinical criteria for early diagnosis, we reviewed 3 post-mortem cases with zygomycosis secondary to hematological diseases. In all cases, an irregular dilatation of pulmonary veins on computed tomography suggested venous invasion by fungal hyphae, which was confirmed at autopsy. In addition, serum samples tested negative for the Aspergillus galactomannan antigen in all cases. These distinguishing radiologic and clinical features may contribute to an earlier diagnosis; more radical treatments, such as amphotericin-B or pulmonary resection; and a more successful outcome for patients with zygomycosis.

Management and outcomes of three cases of rhinocerebral mucormycosis

Mucormycosis is a rare opportunistic infection caused by fungi belonging to Mucorales order. The infection usually starts in the middle or inferior nasal meatus and then spreads to the paranasal sinuses and the orbit. Then it reaches the brain through the ethmoid and the orbit apex and can lead to lethargy, paralysis, and death. The majority of cases of rhinocerebral mucormycosis are diagnosed in patients with immunologic and metabolic disorders. Early diagnosis is fundamental, and so is medical therapy with amphotericin B along with surgical toilet of the compromised tissues. This article presents and discusses the management of 3 cases of rhinocerebral mucormycosis with different onsets, progressions, and outcomes.

Rhinocerebral mucormycosis: experience in 14 patients

Objective:

Mucormycosis is an opportunist, often lethal fungal infection which occurs in immunocompromised patients. We present our experience in 14 patients with this condition.

Patients and methods:

A retrospective chart review was conducted for 14 patients treated for rhinocerebral mucormycosis.

Results:

Nine patients had diabetes mellitus and six had a haematological malignancy. Nine patients had cutaneous and/or palatal necrosis. Eleven patients were treated with amphotericin B and five with liposomal amphotericin B. Endoscopic sinus surgery was performed in five patients with disease limited to the sinonasal cavity; nine patients underwent more extensive surgery. Five patients with disease limited to the sinonasal cavity survived, while nine patients with widely disseminated disease died. Five of the nine diabetic patients died, as did five of the six patients with haematological malignancy.

Conclusion:

Patients with rhinocerebral mucormycosis spreading outside the sinonasal cavity have a poor prognosis.

Unilateral proptosis in a 60-year-old man

A 60-year-old immunocompromised patient developed rapidly progressive proptosis that was secondary to mucormycosis. This life-threatening fungal infection usually is associated with chemosis, proptosis, ophthalmoplegia, and visual loss. The fungus may invade ocular structures, sinuses, and extend into the brain. The standard of care includes correction of the underlying condition, administration of liposomal amphotericin B with posaconazole, and surgical debridement of infected and necrotic tissue. We present a case of unilateral proptosis due to mucormycosis in an immunocompromised patient. The patient was successfully managed medically without exenteration. The indications for exenteration are currently unclear, and no clinical guidelines exist.

Acute invasive fungal rhinosinusitis: Evaluation of 26 patients treated with endonasal or open surgical procedures

OBJECTIVE

Acute invasive fungal rhinosinusitis (AIFRS) is a serious disease with a high mortality and morbidity rate, which almost always affects immunocompromised patients and/or patients with diabetes mellitus. Our purpose was to present the diagnostic and therapeutic management and outcome of these patients.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Twenty-six patients, who were operated on because of AIFRS between September 1999 and June 2009, were retrospectively evaluated in this study. Endoscopic surgery was used in 19 patients, and open surgical debridement was performed in seven patients.

RESULTS

Overall survival rate of the patients in the open surgery group (4 of 7; 57.1%) was similar to that of the endoscopically treated group (9 of 19; 47.3%). Thirteen patients (50%) died of complications related to the underlying disease (9 of 13; 69.2%) and AIFRS (4 of 13; 30.7%). AIFRS-specific survival rate is 76.5 percent; 90 percent (9 of 10) and 57.1 percent (4 of 7) for endoscopic and open surgery groups, respectively. Four patients who died had pathological diagnosis of mucormycosis ( P = 0.52).

CONCLUSION

AIFRS can be successfully treated with a combination of endonasal surgical debridement and antifungal medications. Endonasal approach is suitable for patients diagnosed in the early stages of the disease and provides a less traumatic option in those patients who already have a poor health status. Open surgery should be preferred in the presence of intraorbital extension, palatinal, and/or intracerebral involvement. Reversing the underlying disease process and immunosuppression is as important as the surgical and antifungal treatment.

Hepatic mucormycosis mimicking hilar cholangiocarcinoma: A case report and literature review

Mucormycosis is a rare but invasive opportunistic fungal infection associated with a high mortality rate, and normally occurs in immunocompromised patients. In this report, we describe an immunocompetent patient suffering from hepatic mucormycosis secondary to adrenal mucormycosis, which masquerades as hilar cholangiocarcinoma. After surgical procedure and treatment with amphotericin B and itraconazole, the patient recovered well and had a 2-year infection-free survival. To our knowledge, this special clinical manifestation of hepatic infection as well as adrenal mucormycosis has not been reported to date. Meanwhile, this is the first case of an immunocompetent patient with both adrenal and hepatic mucormycosis who has been treated successfully.

Current therapeutic approaches to fungal infections in immunocompromised hematological patients

Invasive fungal infections are significant causes of morbidity and mortality in patients with hematological malignancies. Patients with acute myeloid leukemia and those who have undergone allogeneic hematopoietic stem cell transplantation are at especially high risk. Various fungal agents are responsible for this complication, but Aspergillus spp. and Candida spp. are the most frequently isolated micro-organisms; less commonly, infections could be caused by Zygomycetes or other rare molds or yeasts. Several new systemically-administered antifungal agents have been approved for clinical use since 2001; these agents include liposomal amphotericin B, voriconazole, caspofungin, and posaconazole, and they represent a major advance in antifungal therapy and have improved the prognosis of patients with hematological malignancies. This review focuses on therapeutic aspects of the management of fungal infections in hematological patients.

Orbitomaxillary mucormycosis (zygomycosis) and the surgical approach to treatment: perspectives from a maxillofacial surgeon

Rhinocerebral or rhino-orbitocerebral (mucormycosis) zygomycosis (ROCZ) usually occurs among patients with poorly controlled diabetes mellitus (especially those with ketoacidosis), solid malignancies, iron overload or extensive burns, in patients undergoing treatment with glucocorticosteroid agents, or in patients with neutropenia related to haematologic malignancies. The disease process starts with inhalation of the fungus into the paranasal sinuses. The fungus may spread to invade the palate, sphenoid sinus, cavernous sinus, orbits or cranially to invade the brain. Pain and swelling precede oral ulceration and the resulting tissue necrosis can result in palatal perforation. Infection can sometimes extend from the sinuses into the mouth and produce painful, necrotic ulcerations of the hard palate. If untreated, infection usually spreads from the ethmoid sinus to the orbit, resulting in the loss of extraocular muscle function and proptosis. Surgical treatment includes the resection of involved tissues of the face, including skin and muscle, any skin of the nose that is involved, maxillary and ethmoid sinuses, necrotic tissue of the temporal area and infratemporal fossa, and orbital exenteration. The keys to successful therapy include suspicion of the diagnosis and early recognition of the signs and symptoms, correction of underlying medical disorders such as ketoacidosis, and aggressive medical and surgical intervention.

Zygomycosis in Italy: a survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in Italy during the European Confederation of Medical Mycology of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin B (L-AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Hard palate perforation in acute lymphoblastic leukemia due to mucormycosis - a case report

Palatal perforation can occur due to trauma, infection and malignancy. Mucormycosis is a rare opportunistic fungal infection caused by an organism of class zygomycetes. Rhinocerebral mucormycosis is the most common type of mucormycosis that typically starts in maxillary antrum in immunocompromised patients. Invasion of surrounding structures leads to necrotizing ulcer of the hard palate and ultimately leads to perforation. Here, we report a case of perforation of the hard palate due to mucormycosis in a eight years child having acute lymphoblastic leukemia (ALL), who was on prolonged chemotherapy and corticosteroid therapy. This case is being reported for its rarity. The aim of presenting this case report is to emphasize that the infection due to mucomycosis should be included in the differential diagnosis of hard palate perforation in ALL patients who are immunocompromised.

[The diagnostic and therapeutical difficulties of acute (fulminant) invasive mycotic rhinosinusitis]

The autors present the diagnostic and therapeutical difficulties of acute (fulminant) invasive mycotic rhinosinusitis. A case report of mycotic rhinosinusogenes meningitis in 50 years old woman is described in this paper. The intensive pharmacological and surgical treatment was performed. The result was successful, however the optical nerve was damaged.

Detection of a molecular biomarker for zygomycetes by quantitative PCR assays of plasma, bronchoalveolar lavage, and lung tissue in a rabbit model of experimental pulmonary zygomycosis

We developed two real-time quantitative PCR (qPCR) assays, targeting the 28S rRNA gene, for the diagnosis of zygomycosis caused by the most common, clinically significant Zygomycetes. The amplicons of the first qPCR assay (qPCR-1) from Rhizopus, Mucor, and Rhizomucor species were distinguished through melt curve analysis. The second qPCR assay (qPCR-2) detected Cunninghamella species using a different primer/probe set. For both assays, the analytic sensitivity for the detection of hyphal elements from germinating sporangiospores in bronchoalveolar lavage (BAL) fluid and lung tissue homogenates from rabbits was 1 to 10 sporangiospores/ml. Four unique and clinically applicable models of invasive pulmonary zygomycosis served as surrogates of human infections, facilitating the validation of these assays for potential diagnostic utility. For qPCR-1, 5 of 98 infarcted lung specimens were positive by qPCR and negative by quantitative culture (qCx). None were qCx positive only. Among 23 BAL fluid samples, all were positive by qPCR, while 22 were positive by qCx. qPCR-1 detected Rhizopus and Mucor DNA in 20 (39%) of 51 serial plasma samples as early as day 1 postinoculation. Similar properties were observed for qPCR-2, which showed greater sensitivity than qCx for BAL fluid (100% versus 67%; P = 0.04; n = 15). The assay detected Cunninghamella DNA in 18 (58%) of 31 serial plasma samples as early as day 1 postinoculation. These qPCR assays are sensitive and specific for the detection of Rhizopus, Mucor, Rhizomucor, and Cunninghamella species and can be used for the study and detection of infections caused by these life-threatening pathogens.

Eleven cases of mucormycosis with atypical clinical manifestations in diabetic patients

OBJECTIVE

We retrospectively investigated 11 cases of mucormycosis with atypical clinical features accompanied by diabetes mellitus and discussed clinical features, results of laboratory investigations and radiological examinations and treatment outcomes of each case.

METHODS

Eleven cases of mucormycosis presenting to our clinic between January 2002 and October 2006 were retrospectively investigated.

RESULTS

We will present a total of 11 cases of mucormycosis, including 2 cases of mucormycosis with orbital apex syndrome as an initial sign, 2 cases of mucormycosis involving the carotid artery and cavernous sinus with the resultant fatal stroke, 1 case of disseminated mucormycosis with atypical clinical manifestations. Mucormycosis was accompanied by type II diabetes mellitus in five cases, chronic renal failure and type II diabetes mellitus in four cases and type II diabetes mellitus and chronic myelocytic leukemia in two cases. None of them had diabetic ketoacidosis. Only one patient recovered but with sequels: blindness, complete ophthalmoplegia of the right eye. Ten patients died of mucormycosis.

CONCLUSION

In fact, mucormycosis is a fungal infection which may involve all organs and systems. Mucormycosis must be considered in patients presenting with orbital or preorbital sellulitis, even in the absence of ketoacidosis as in our cases.

Automated and manual methods of DNA extraction for Aspergillus fumigatus and Rhizopus oryzae analyzed by quantitative real-time PCR

Quantitative real-time PCR (qPCR) may improve the detection of fungal pathogens. Extraction of DNA from fungal pathogens is fundamental to optimization of qPCR; however, the loss of fungal DNA during the extraction process is a major limitation to molecular diagnostic tools for pathogenic fungi. We therefore studied representative automated and manual extraction methods for Aspergillus fumigatus and Rhizopus oryzae. Both were analyzed by qPCR for their ability to extract DNA from propagules and germinated hyphal elements (GHE). The limit of detection of A. fumigatus and R. oryzae GHE in bronchoalveolar lavage (BAL) fluid with either extraction method was 1 GHE/ml. Both methods efficiently extracted DNA from A. fumigatus, with a limit of detection of 1 x 10(2) conidia. Extraction of R. oryzae by the manual method resulted in a limit of detection of 1 x 10(3) sporangiospores. However, extraction with the automated method resulted in a limit of detection of 1 x 10(1) sporangiospores. The amount of time to process 24 samples by the automated method was 2.5 h prior to transferring for automation, 1.3 h of automation, and 10 min postautomation, resulting in a total time of 4 h. The total time required for the manual method was 5.25 h. The automated and manual methods were similar in sensitivity for DNA extraction from A. fumigatus conidia and GHE. For R. oryzae, the automated method was more sensitive for DNA extraction of sporangiospores, while the manual method was more sensitive for GHE in BAL fluid.

Zygomycosis presenting as acute myocardial infarction during hematological malignancies

Here we report two patients with hematological malignancies associated with complications of fatal cardiac zygomycosis. The first case, a 72-year-old man with myelodysplastic syndrome being treated with low-dose cytarabine, died of sudden cardiac arrest. An autopsy revealed disseminated zygomycosis accompanied with occlusion of the coronary artery by fungal thrombi. The second case, a 52-year-old woman with acute lymphoblastic leukemia, developed febrile neutropenia and skin eruptions with induration on the face and extremities during the first induction chemotherapy. She experienced sudden bradycardia with unstable hemodynamics and died of acute myocardial infarction. Histological examination of a skin biopsy demonstrated zygomycosis. In light of the above, it should be kept in mind that cardiac zygomycosis might occur in hematologically compromised patients presenting with acute myocardial infarction.

Orbital Exenteration: A Dilemma in Mucormycosis Presented with Orbital Apex Syndrome

Background

Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic, fungal paranasal sinus infection. The most critical decision in the management of rhino-orbital mucormycosis is whether the orbit should be exenterated. The literature fails to provide a broad base of information of how physicians determine the need for exenteration in daily practice. The decision for exenteration often depends on the judgment of the treating otolaryngologist. The authors report their experience and outline that orbital exenteration may not be mandatory in all cases of rhino-orbital mucormycosis.

Methods

The medical records from Celal Bayar University Medical Faculty Department of Otorhinolaryngology/Head and Neck Surgery were retrospectively searched from 1995 to 2007 for three cases with rhino-orbital mucormycosis, treated without orbital exenteration.

Results

All patients with rhino-orbital mucormycosis who were treated without exenteration survived.

Conclusion

The favorable outcome was attributable to rapid correction of the underlying medical condition; wide local excision and debridement of all involved and devitalized sinonasal and periorbital tissue, while establishing adequate sinus and orbital drainage; daily endoscopic assessment with multiple sinus debridement when necessary; daily irrigation of the involved areas; and high-dose i.v. amphotericin B.

Invasive zygomycosis: update on pathogenesis, clinical manifestations, and management

Zygomycosis is an increasingly common infection in immunocompromised patients. Advances in the understanding of Zygomycetes pathobiology and the introduction of new drugs with improved activity and tolerability for treatment of zygomycosis have improved the prospects of effectively controlling this devastating infection. Further reductions in mortality will require improved diagnostic and novel therapeutic approaches for this group of aggressive opportunistic molds.

Successful use of posaconazole in a pediatric case of fungal necrotizing fasciitis

OBJECTIVE

To report a pediatric case of posttraumatic fungal fasciitis treated successfully with a combination including posaconazole.

DESIGN

Case report.

SETTING

Pediatric critical care unit at Antwerp University Hospital.

PATIENT

A 12-yr-old female polytrauma patient, suffering from extensive skin and muscle injuries, developed fasciitis. Two fungi (Mucor and Trichosporon species) were isolated. The necrotic tissues were aggressively excised, hyperbaric oxygen therapy was applied, and oral posaconazole was added to the initial amphotericin B treatment. The patient made an excellent recovery.

CONCLUSIONS

A combination of a high index of suspicion, early aggressive surgery, hyperbaric oxygen, and the association of amphotericin B and posaconazole led to a successful outcome in a case of fungal necrotizing fasciitis. After decades of disappointing amphotericin B treatment in spite of acceptable in vitro activity, the combination with the new triazole posaconazole seems promising.

Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation

Disseminated mucormycosis is a rare, mostly fatal infectious complication in immunocompromised haematological patients. The purpose of our study was to describe the multiorgan manifestations of disseminated mucormycosis documented at CT and MRI in four patients and correlate these with the pathological findings and patient outcome. Irrespective of the site of infection, infarction or haemorrhage are the constant features of invasive mycosis. Identification of one or both of these two major imaging findings in immunocompromised patients should be regarded as an indicator of possible infection by angiotropic fungi, including the genre Mucorales.

Emerging echinocandins for treatment of invasive fungal infections

The echinocandins are a new class of antifungals, developed in response to the need for safe and effective antifungals for the treatment of invasive fungal infections. These agents work by inhibiting 1,3-beta-d-glucan synthase, an enzyme essential for production of cell walls in select fungi. Echinocandins appear to demonstrate favourable activity in vitro against a variety of yeasts (including both Candida albicans and non-albicans Candida) as well as select moulds (including Aspergillus spp.) In general, all echninocandins demonstrate a favourable safety profile and require once-daily parenteral administration. Caspofungin is the first of these agents to be available in the US, and is approved for empirical antifungal therapy in febrile neutropenic patients, candidaemia and select forms of invasive candidiasis, and for management of invasive aspergillosis in patients refractory to or intolerant of other therapies. Micafungin was recently approved by the FDA for treatment of oesophageal candidiasis, and for the prophylaxis of fungal infections in haematopoietic stem cell transplant recipients. Emerging data indicate micafungin may have an important role in the treatment of invasive forms of candidiasis. Anidulafungin is an echinocandin approved in the US for treatment of candidaemia and oesophageal candidiasis. Aminocandin (HMR-3702, IP-960) is an investigational agent, with published experience limited to in vitro studies and animal models of infection.

Fungal CNS infections in patients with hematologic malignancy

Various fungal agents can cause CNS infections. CNS fungal infections may present as a mass (i.e., brain abscess) typically in the course of aspergillosis or zygomycosis, or may primarily involve the meninges (i.e., meningitis), as can be observed in patients with candidiasis or cryptococcosis. Most commonly, fungal brain abscesses are due to aspergillosis. CNS aspergillosis is observed particularly in acute leukemia and allogeneic hemopoietic stem cell transplantation patients. Usually, aspergillosis is localized in the lungs and secondarily spreads to the brain; only in few cases does it develop as solitary localization of CNS. In these conditions, diagnosis is very difficult because signs and symptoms can be completely aspecific. Diagnosis can often be performed only through aggressive procedures (i.e., stereotactic puncture). Zygomycetes are the second most frequent cause of brain abscesses. CNS involvement is higher than in the course of invasive aspergillosis, and this fungal complication is also characterized by a high mortality rate. In vitro and in vivo studies demonstrated that only posaconazole and lipid formulations of amphotericin B present some possibility of success in the treatment of zygomycosis, but the pharmacologic approach should always be associated with surgery. Among molds, other agents (i.e., Fusarium and Scedosporium) may also be responsible for fungal abscess. More rarely during the course of a hematologic malignancy, a meningeal candidiasis or cryptococcosis may be observed. This review mainly focuses on the epidemiology, clinical manifestations, diagnosis and management strategies of all cases of CNS fungal infections in hematologic patients.

Tratamiento de las infecciones fúngicas invasoras

Invasive fungal infections have increased progressively in the last decades, producing elevated morbidity and mortality. In recent years, there have been numerous advances in the treatment of these diseases, with the introduction of new drugs in clinical practice and the information derived from several types of studies. This has improved the prognosis of some invasive fungal infections and increased the therapeutic options in various clinical situations. This new knowledge must be assessed to determine its application in clinical practice, taking into account available scientific evidence and clinical experience. With this aim, the Andalusian Society of Infectious Diseases has developed this consensus document containing recommendations for the treatment of the invasive fungal infections.

Zygomycoses in patients with acute leukaemia

Zygomycoses are rare invasive mould infections which mainly occur in immunocompromised patients, especially during prolonged neutropenia. The high mortality rate is due to a high failure rate of both intravital diagnosis and treatment. Exact diagnosis requires microscopic examination and proof by culture. The treatment consists of amphotericin B and surgical debridement. We report four recent cases of zygomycosis among 89 patients with intensively treated acute leukaemia at our institution. Three cases were breakthrough infections since the patients were under voriconazole treatment prior to diagnosis of zygomycosis. Only one patient had premortal diagnosis (paranasal sinus infection) and showed clinical response with amphotericin B and surgical debridement. A review of the literature of these emerging fungal infections is given and is focused on patients with acute leukaemia. In addition, the importance of autopsy as a tool for quality control and epidemiological studies is pointed out.

Posaconazole as salvage therapy for zygomycosis

Zygomycosis, an infection that is associated with significant morbidity and mortality, is becoming common in immunocompromised patients. Posaconazole is a new extended-spectrum azole antifungal that has demonstrated in vitro and in vivo activity against zygomycetes. This report provides the results from the first 24 patients with active zygomycosis who were enrolled in two open-label, nonrandomized, multicentered compassionate trials that evaluated oral posaconazole as salvage therapy for invasive fungal infections. Posaconazole was usually given as an oral suspension of 200 mg four times a day or 400 mg twice a day. Eleven (46%) of the infections were rhinocerebral. Duration of posaconazole therapy ranged from 8 to 1,004 days (mean, 292 days; median, 182 days). Rates of successful treatment (complete cure and partial response) were 79% in 19 subjects with zygomycosis refractory to standard therapy and 80% in 5 subjects with intolerance to standard therapy. Overall, 19 of 24 subjects (79%) survived infection. Survival was also associated with surgical resection of affected tissue and stabilization or improvement of the subjects' underlying illnesses. Failures either had worsening of underlying illnesses or requested all therapy withdrawn; none of the failures received more than 31 days of posaconazole. Posaconazole oral solution was well tolerated and was discontinued in only one subject due to a drug rash. Posaconazole appears promising as an oral therapy for zygomycosis in patients who receive required surgery and control their underlying illness.