Recent advances in the management of mucormycosis: from bench to bedside

Mucormycosis in Iran: a systematic review

Fungi in the order Mucorales cause acute, invasive and frequently fatal infections in susceptible patients. This study aimed to perform a systematic review of all reported mucormycosis cases during the last 25 years in Iran. After a comprehensive literature search, we identified 98 cases in Iran from 1990-2015. The mean patient age was 39.8 ± 19.2 years. Diabetes was the most common underlying condition (47.9%), and 22.4% of the patients underwent solid organ or bone marrow transplantation. The most common clinical forms of mucormycosis were rhinocerebral (48.9%), pulmonary (9.2%) and cutaneous (9.2%). Eight cases of disseminated disease were identified. Overall mortality in the identified cases was 40.8%, with the highest mortality rate in patients diagnosed with disseminated infection (75%). The mortality rate in rhinocerebral infection patients was significantly lower (45.8%). Rhinocerebral infection was the most common clinical manifestation in diabetes patients (72.9%). Patients were diagnosed using various methods including histopathology (85.7%), microscopy (12.3%) and culture (2.0%). Rhizopus species were the most prevalent (51.7%), followed by Mucor species (17.2%). Sixty-nine patients were treated with a combination of surgery and antifungal therapy (resulting survival rate, 66.7%). Owing to the high mortality rate of advanced mucormycosis, early diagnosis and treatment may significantly improve survival rates. Therefore, increased monitoring and awareness of this life-threatening disease is critical.

Mucorales-Specific T Cells in Patients with Hematologic Malignancies

Background

Invasive mucormycosis (IM) is an emerging life-threatening fungal infection. It is difficult to obtain a definite diagnosis and to initiate timely intervention. Mucorales-specific T cells occur during the course of IM and are involved in the clearance of the infection. We have evaluated the feasibility of detecting Mucorales-specific T cells in hematological patients at risk for IM, and have correlated the detection of such cells with the clinical conditions of the patients.

Methods and Findings

By using an enzyme linked immunospot assay, the presence of Mucorales-specific T cells in peripheral blood (PB) samples has been investigated at three time points during high-dose chemotherapy for hematologic malignancies. Mucorales-specific T cells producing interferon-γ, interleukin-10 and interleukin-4 were analysed in order to detect a correlation between the immune response and the clinical picture. Twenty-one (10.3%) of 204 patients, accounting for 32 (5.3%) of 598 PB samples, tested positive for Mucorales-specific T cells. Two groups could be identified. Group 1, including 15 patients without signs or symptoms of invasive fungal diseases (IFD), showed a predominance of Mucorales-specific T cells producing interferon-gamma. Group 2 included 6 patients with a clinical picture consistent with invasive fungal disease (IFD): 2 cases of proven IM and 4 cases of possible IFD. The proven patients had significantly higher number of Mucorales-specific T cells producing interleukin-10 and interleukin-4 and higher rates of positive samples by using derived diagnostic cut-offs when compared with the 15 patients without IFD.

Conclusions

Mucorales-specific T cells can be detected and monitored in patients with hematologic malignancies at risk for IM. Mucorales-specific T cells polarized to the production of T helper type 2 cytokines are associated with proven IM and may be evaluated as a surrogate diagnostic marker for IM.

Mucormycosis: a 10-year experience at a tertiary care center in Turkey

BACKGROUND/AIM

Mucormycosis is a rare invasive fungal infection most commonly encountered in the immunocompromised host. We analyzed 51 adult patients treated for mucormycosis between 2003 and 2013 and recorded at a tertiary university hospital in Turkey.

MATERIALS AND METHODS

We examined the following data for all patients: age, sex, predisposing disease, symptoms, treatment, surgical procedure, concomitant infections, intensive care requirement, and outcomes.

RESULTS

During the study period 51 cases of mucormycosis were documented; 54.9% of the patients were female. The mean age was 44.2 ± 18.2 years. Rhinocerebral presentation was reported in 94.1% of patients. Almost all patients (88.2%) had at least one risk factor. The common predisposing factors were hematologic malignancies (52.9%), diabetes mellitus (25.5%), and solid malignancies (5.8%). The most common initial symptoms were fever, cellulitis, and facial pain. The primary medication used was liposomal amphotericin B or conventional amphotericin B. Surgery was performed in 94.1% of patients. Mortality was 52.9%.

CONCLUSION

Our study revealed that mucormycosis continues to be a mortal disease in about half of the cases. Our findings indicate that treatment with L-AMB is associated with a favorable response. Also, in the case of facial pain, the low mortality rate may indicate the importance of early diagnosis.

Investigation and Management of a Rhizomucor Outbreak in a Pediatric Cancer Hospital in Egypt

We describe an outbreak of mucormycosis in a pediatric oncology hospital during December 2010 and the measures taken to stop it. The outbreak began with two consecutive cases of laboratory-documented mucormycosis infections within 1 week. Investigations to track the source were conducted immediately. Air plate cultures from machines and ducts supplying patients' rooms revealed the growth of Rhizomucor. Of five affected patients, all had acute leukemia and three were histopathologically proven. All patients were treated with liposomal amphotericin B after mucormycosis was diagnosed. Posaconazole was used as a secondary prophylaxis in one case. Three patients died.

VISUAL OUTCOME WITH A MULTIMODALITY APPROACH IN A CASE OF RHINOORBITO- CEREBRAL MUCORMYCOSIS

BACKGROUND

Rhinoorbito-cerebral mucormycosis is an uncommon and acute fungal infection which runs a fulminant course. Uncontrolled diabetes mellitus is the most common predisposing factor.

AIM

To assess the outcome of a poorly controlled diabetic with Rhinoorbito-cerebral mucormycosis using a multi-modality management.

METHODOLOGY

We report a case of a 57-year old male who presented to us with proptosis and total external ophthalmoplegia diagnosed with rhino-orbito-cerebral mucormycosis. Patient was started on conventional intravenous amphotericin B to which he developed systemic toxicity. As an alternative, a combination therapy of oral posacanazole along with peribulbar amphotericin B injections for a more localised effect was initiated.

RESULTS

He had a favourable outcome with dramatic improvement in vision and marginal recovery of extra ocular movements within 20 days of initiation of combination therapy.

CONCLUSION

Rhinoorbito-cerebral mucormycosis is a major diagnostic dilemma with quick progression and a high mortality. Prompt medical management with a multi-modality approach can save the patient from orbital exenteration.

Comparison of the EUCAST and CLSI Broth Microdilution Methods for Testing Isavuconazole, Posaconazole, and Amphotericin B against Molecularly Identified Mucorales Species

We compared EUCAST and CLSI antifungal susceptibility testing (AFST) methods for triazoles and amphotericin B against 124 clinical Mucorales isolates. The EUCAST method yielded MIC values 1- to 3-fold dilutions higher than those of the CLSI method for amphotericin B. The essential agreements between the two methods for triazoles were high, i.e., 99.1% (voriconazole), 98.3% (isavuconazole), and 87% (posaconazole), whereas it was significantly lower for amphotericin B (66.1%). Strategies for harmonization of the two methods for Mucorales AFST are warranted.

The Infectious and Noninfectious Dermatological Consequences of Flooding: A Field Manual for the Responding Provider

Meteorological data show that disastrous floods are increasingly frequent and more severe in recent years, perhaps due to climatic changes such as global warming. During and after a flood disaster, traumatic injuries, communicable diseases, chemical exposures, malnutrition, decreased access to care, and even mental health disorders dramatically increase, and many of these have dermatological manifestations. Numerous case reports document typical and atypical cutaneous infections, percutaneous trauma, immersion injuries, noninfectious contact exposures, exposure to wildlife, and exacerbation of underlying skin diseases after such disasters as the 2004 Asian tsunami, Hurricane Katrina in 2005, and the 2010 Pakistan floods. This review attempts to provide a basic field manual of sorts to providers who are engaged in care after a flooding event, with particular focus on the infectious consequences. Bacterial pathogens such as Staphylococcus and Streptococcus are still common causes of skin infections after floods, with atypical bacteria also greatly increased. Vibrio vulnificus is classically associated with exposure to saltwater or brackish water. It may present as necrotizing fasciitis with hemorrhagic bullae, and treatment consists of doxycycline or a quinolone, plus a third-generation cephalosporin and surgical debridement. Atypical mycobacterial infections typically produce indolent cutaneous infections, possibly showing sporotrichoid spread. A unique nontuberculous infection called spam has recently been identified in Satowan Pacific Islanders; combination antibiotic therapy is recommended. Aeromonas infection is typically associated with freshwater exposure and, like Vibrio infections, immunocompromised or cirrhotic patients are at highest risk for severe disease, such as necrotizing fasciitis and sepsis. Various antibiotics can be used to treat Aeromonas infections. Melioidosis is seen mainly in Southeast Asia and Australia, particularly in rice farmers, and can remain latent for many years before presenting as the host's immunocompetence wanes. It can present with a variety of skin findings or as a nonspecific febrile illness, and preferred treatment consists of ceftazidime or a carbapenem with trimethoprim/sulfamethoxazole (TMP/SMX) for 2 weeks, then continuing TMP/SMX for at least 3 months. Leptospirosis is a waterborne zoonosis that is often prevalent after heavy rains or flooding. Different forms exist, including Fort Bragg fever, which produces a distinctive erythematous papular rash on the shins. Doxycycline is often sufficient; however, volume and potassium repletion may be necessary if renal involvement exists. Chromobacterium violaceum infection may occur after open skin is exposed to stagnant or muddy water. Cultured colonies produce a unique violacein pigment, and treatment typically consists of a carbapenem. Both typical and atypical fungal infections are increased in the flooding disaster scenario, such as dermatophytosis, chromoblastomycosis, blastomycosis, and mucormycosis. Appropriate antifungals should be used. In addition, land inundated with water expands the habitat for parasites and/or vectors, thus increased vigilance for regional parasitic infections is necessary after a flood. Lastly, noninfectious consequences of a flooding disaster are also common and include miliaria, immersion foot syndromes, irritant and allergic contact dermatitis, traumatic wounds and animal bites, and arthropod assault, as well as exacerbation of existing skin conditions such as atopic dermatitis, psoriasis, and alopecia areata due to increased stress or nonavailability of daily medications.

Neuronavigation-guided endoscopic endonasal resection of extensive skull base mucormycosis complicated with cerebral vasospasm

A 24-year-old woman presented with double vision since 6 months. Examination revealed left eye ptosis and bilateral abducens nerve palsy. Brain computed tomographic scan and magnetic resonance imaging revealed a bone-eroding mass lesion located in the middle skull base, occupying the posterior ethmoidal cells, the planum sphenoidale, the sphenoid sinus, the lateral recesses of the sphenois sinus, the pterygoid apexes, and the middle and lower clivus, with compression of the inferior wall of the cavernous sinus and the parasellar and paraclival parts of the internal carotid artery. The patient was operated on with extended endoscopic endonasal approach guided with neuronavigation. Total mass resection was achieved. Histopathologic examination revealed mucormycosis infectious mass. On postoperative day 5, the patient developed right hemiplegia, and brain imaging revealed left internal carotid vasospasm. After treatment, the patient improved and was discharged.

Mucormycosis: what emergency physicians need to know?

BACKGROUND

Mucormycosis is a rare presentation for patients in the emergency department (ED), primarily affecting immunocompromised patients. Multiple forms of infection are present, and with poor prognosis, ED diagnosis and treatment of this deadly condition are necessary.

OBJECTIVE OF REVIEW

The aim of this review is to provide an overview of the presentations and forms of mucormycosis, diagnosis, and treatment of this deadly disease.

DISCUSSION

This review provides background on the fungi causing mucormycosis, which are prevalent in nature. The article discusses the risk factors for infection with mucormycosis, as normal hosts are able to clear the disease, but immunocompromised and diabetic patients are at risk for organism inoculation and spread. The fungi are angioinvasive and cause necrosis. This article describes the various forms of the disease: rhino-orbital-cerebral, pulmonary, central nervous system, gastrointestinal, renal, disseminated, and cutaneous. Finally, this review evaluates diagnosis, treatment, and prognosis.

CONCLUSION

Emergency department diagnosis and treatment are necessary in patients with infection with mucormycosis. Physicians should be suspicious of this disease in immunocompromised and diabetic patients. Treatment requires antifungal agents such as amphotericin B and surgical debridement. Prognosis is poor.

Infectious complications in children with acute lymphoblastic leukemia treated in low-middle-income countries

Infections are the most important cause of morbidity and mortality in children treated for acute lymphoblastic leukemia (ALL). The rates of infection-associated mortality are up to 10-times higher in low- and middle-income countries (LMIC) than in high-income countries. The prevention, early recognition and management of infectious complications is especially challenging in LMIC because of disease and poverty-related factors, as well as the shortage of trained personnel, supplies, diagnostic tools and adequate organizational infrastructure. Children in LMIC with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens and opportunistic microorganisms. This review summarizes the challenges of managing the major categories of infections in children receiving treatment for ALL and provides updated practical recommendations for preventing and managing these infections in LMIC.

Invasive mould sinusitis in patients with haematological malignancies: a 10 year single-centre study

OBJECTIVES

Invasive mould sinusitis (IMS) is a severe infection in patients with haematological malignancies. Because of a paucity of contemporaneous data about IMS, we sought to evaluate clinical aspects and outcome of IMS in these patients.

METHODS

The records of adult haematological malignancy patients with proven or probable IMS over a 10 year period were reviewed retrospectively.

RESULTS

We identified 44 patients with IMS. Mucorales were isolated in 13 (35.1%) patients and Fusarium and Aspergillus were isolated in 9 (24.3%) patients each. Patients with IMS owing to Mucorales were more likely to have a history of diabetes mellitus (P = 0.003) and high-dose corticosteroid use (P = 0.03). Thirty-five (80%) patients received antifungal combinations and 36 (82%) underwent surgical debridement. The 12 week IMS-attributable mortality was 36.4% (16 patients). A relapsed and/or refractory haematological malignancy was an independent risk factor for 6 week IMS-attributable (P = 0.038), 12 week all-cause (P = 0.005) and 12 week IMS-attributable (P = 0.0015) mortality. Neutrophil count <100/µL and lymphocyte count <200/µL were associated with increased 12 week IMS-attributable and 6 week all-cause mortality, respectively (P = 0.044 and 0.013). IMS due to Aspergillus was an independent risk factor for both 12 week all-cause (P = 0.011) and IMS-attributable (P = 0.026) mortality. Initial antifungal therapy with a triazole-containing regimen was associated with decreased 6 week all-cause (P = 0.032) and IMS-attributable (P = 0.038) mortality. Surgery was not an independent factor for improved outcome.

CONCLUSIONS

Despite combined medical and surgical therapy, IMS had high mortality. Mortality risk factors were relapsed and/or refractory malignancy, cytopenia and Aspergillus infection in this study.

Rhino-orbito-cerebral mucormycosis. Management strategies to avoid or limit intracraneal affection and improve survival

Mucormycosis is a rare opportunistic infection. The aim of the study was to review the cases presented in our department with rhino-orbital mucormycosis and to describe the clinical protocol, diagnosis and therapy used in these patients. We conducted a retrospective, longitudinal, descriptive study, in which we evaluated the records of patients with rhino-orbital mucormycosis in the period from January to October 2013. We found 5 cases. Pterigomaxillary fossa disease was found in 100% of our patients. Medical and surgical treatment performed early by extensive endoscopic debridement (including debridement and resection of pterygomaxillary fossa) and orbital exenteration in patients presenting with orbitary apex syndrome in conjunction with the ophthalmology department of our hospital, with excellent results in the survival of our patients (all patients survived).

How to treat fungal infections in ICU patients

Fungal infections represent a major burden in the critical care setting with increasing morbidity and mortality. Candidiasis is the leading cause of such infections, with C. albicans being the most common causative agent, followed by Aspergillosis and Mucormycosis. The diagnosis of such infections is cumbersome requiring increased clinical vigilance and extensive laboratory testing, including radiology, cultures, biopsies and other indirect methods. However, it is not uncommon for definitive evidence to be unavailable. Risk and host factors indicating the probability of infections may greatly help in the diagnostic approach. Timely and adequate intervention is important for their successful treatment. The available therapeutic armamentarium, although not very extensive, is effective with low resistance rates for the newer antifungal agents. However, timely and prudent use is necessary to maximize favorable outcomes.

Isolated Mucormycotic Spondylodiscitis of Lumbar Spine-A Rare Case Report

INTRODUCTION

Mucormycosis is life threatening infection rarely affecting musculoskeletal system and spinal involvement is extremely rare with only two cases reported in English literature.

CASE REPORT

We present this rare case of spondylodiscitis with lumbar vertebral osteomyelitis due to mucormycosis in a patient with chronic kidney disease on haemodialysis diagnosed by CT guided biopsy and highlight its clinico -radiological presentation and management principles.

CONCLUSION

Thus, as the incidence of Mucorales infection increase due to increase in patients with predisposing factors, the unusual sites of affection increase. Treating clinician should have a high vigilance in patients with predisposing factors. Although there is dramatic improvement in the treatment modalities of mucormycosis, still the mortality is high. Early diagnosis is important to prevent dissemination and timely intervention in order to reduce morbidity and mortality. A well equipped multidisciplinary approach for clinico-radiological assessment and management is necessary.

Mucormycosis Rhinosinusitis at Diagnosis of Acute Lymphoblastic Leukemia: Diagnostics and Management Challenges in a Low-Middle-income Country

We present the case of an adolescent with mucor rhinosinusitis diagnosed concomitantly with acute lymphoblastic leukemia at a hospital in Tegucigalpa, Honduras. We also discuss the challenges faced in the dual management of hematologic malignancies and invasive fungal disease in a low-middle-income country, such as access to diagnostics, immunosuppressants, imaging, and antifungals. Despite these shortcomings, the patient was successfully treated for both the diseases. Low-middle-income country hospitals can effectively treat invasive fungal diseases by providing adequate diagnostic and support services, which can improve the outcomes of pediatric cancer patients.

How should we manage a patient with invasive mucoromycosis who develops life-threatening reaction to amphotericin B? Report of two cases and literature review

This report presents two cases of invasive rhino-orbital mucormycosis who had life-threatening reactions to amphotericin B. Both cases were treated with a combination of posaconazole–caspofungin favorably with no evidence of recurrence upon long-term follow-up. To our knowledge, this is the first report of successful treatment of invasive mucormycosis with azole–echinocandin combination. It may suggest that caspofungin exerts additional or even synergistic antimucoral effects to posaconazole.

Rhinocerebral mucormycosis: a retrospective study

Mucormycosis is an acute often fatal infection caused by fungi of family mucoracea (Kauffman and Malani Curr Infect Dis Rep 9(6):435-440). The principal pathogens in this family are rhizopus, mucor and absidia species. Mucoracea are found in soil, decaying vegetation and other organic matter. Mucormycosis is a polymorphic disease with diverse clinical manifestation. It is divided into rhinocerebral, pulmonary, cutaneous, cardiac, gastrointestinal and disseminated. Rhinocerebral mucormycosis the most commonest manifestation of mucormycosis is usually a fatal fulminant infection. Rhinocerebral mucormycosis can be further divided into rhino-maxillary and rhino-orbito-cerebral. The disease commonly occur in diabetics who have ketoacidosis but is also seen in severely debilitated or immunosuppressed patients. It has also been reported from otherwise normal individuals. Early diagnosis and treatment is mandatory for a successful management of this infection.

Pulmonary tuberculosis and mucormycosis co-infection in a diabetic patient

Uncontrolled diabetes mellitus is associated with a variety of infections which pose management difficulties. Herein, we report a case of diabetic patient who developed combined pulmonary tuberculosis and mucormycosis. The case illustrates management of this rare co-infection which despite being potentially fatal was treated successfully.

Mucormycosis: a rare fungal infection in tornado victims

This article reviews four immunocompetent patients who developed a rare fungal infection, mucormycosis, secondary to multiple traumatic injuries sustained during an EF-5 tornado in Joplin, MO. Commonly found in soil and decaying organic matter, mucorales are fungi associated with soft tissue and cutaneous infections. Onset of this fungal infection can occur without clinical signs, presenting several days to several weeks after injury, delaying diagnosis. A multidisciplinary treatment approach including aggressive antifungal therapy and aggressive surgical debridement is critical. This diagnosis should be considered in all patients presenting with injuries sustained from high-velocity embedment of debris such as natural disasters or explosions. We present four cases of mucormycosis, species Apophysomyces trapeziformis. Data reported includes predisposing factors, number of days between injury and diagnosis of mucormycosis, surgical treatment, antifungal therapy, outcomes, and potential risk factors that may have contributed to the development of mucormycosis.

Infectious Complications

Infections remain a cause of significant morbidity and mortality following hematopoietic stem cell transplantation (HSCT). The conditioning regimen (chemotherapy, radiation therapy), mucosal damage, type of transplant, immune suppressive therapy, and graft-versus-host disease (GVHD) all predispose the HSCT recipient to infection. Abnormal B- and T-lymphocyte function results in impaired humoral and cellular immunity, respectively. Neutrophil function is impaired by the use of corticosteroids and other medications. Hypogammaglobulinemia and functional asplenia are common. The occurrence of infections in an individual patient varies according to the phase of the transplant process and reflects the type(s) of immune defect(s), underlying disease, endogenous host flora, exposure history, and pre-treatment infections.

Successful Management of a Unique Condition of Isolated Intracranial Mucormycosis in an Immunocompetent Child

This report describes a unique case of isolated intracranial mucormycosis of a slowly progressive nature in a healthy immunocompetent child. A 4-year-old girl with a clear medical and surgical history presented with complaints of right side facial asymmetry and unsteady gait for a period of 10 months. Clinical and radiographic investigations revealed right-sided lower motor neuron facial palsy caused by an infiltrative lesion on the right cerebellopontine angle. Initial surgical debulking was performed, a biopsy was sent for histopathological examination, and a course of prophylactic antibiotic and antifungal drugs was prescribed. The pathological report confirmed the mucormycosis fungal infection, and intravenous amphotericin B was administered for 3 weeks. One month after admission, the patient left the hospital with complete recovery. Follow-ups after 4, 8 and 12 weeks revealed no sensory or motor neurological deficits. In conclusion, this is a unique case of mucormycosis with regard to the nature and location of the infection, along with the host being a healthy child. Initial surgical exploration is a very critical step in the early diagnosis and treatment of such rare conditions.

Invasive rhino-orbito-cerebral mucormycosis in a diabetic patient - the need for prompt treatment

Mucormycosis is a rare life threatening fungal infection predominately seen in immunocompromised or diabetic patients. The following case is of a known type II diabetic patient who presented with sepsis and sudden unilateral loss of vision secondary to infective rhino-orbito-cerebral mucormycosis. Treatment of the condition required extensive surgical intervention and medical management for a life saving outcome.

Gastrointestinal mucormycosis requiring surgery in adults with hematologic malignant tumors: literature review

BACKGROUND

Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential.

METHOD

Case report and literature review.

RESULTS

Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%.

CONCLUSION

Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.

Combat-Related Invasive Fungal Wound Infections

Combat-related invasive fungal (mold) wound infections (IFIs) have emerged as an important and morbid complication following explosive blast injuries among military personnel. Similar to trauma-associated IFI cases among civilian populations, as in agricultural accidents and natural disasters, these infections occur in the setting of penetrating wounds contaminated by environmental debris. Specific risk factors for combat-related IFI include dismounted (patrolling on foot) blast injuries occurring mostly in southern Afghanistan, resulting in above knee amputations requiring resuscitation with large-volume blood transfusions. Diagnosis of IFI is based upon early identification of a recurrently necrotic wound following serial debridement and tissue-based histopathology examination with special stains to detect invasive disease. Fungal culture of affected tissue also provides supportive information. Aggressive surgical debridement of affected tissue is the primary therapy. Empiric antifungal therapy should be considered when there is a strong suspicion for IFI. Both liposomal amphotericin B and voriconazole should be considered initially for treatment since many of the cases involve not only Mucorales species but also Aspergillus or Fusarium spp., with narrowing of regimen based upon clinical mycology findings.

Clinical challenge: fatal mucormycotic osteomyelitis caused by Rhizopus microsporus despite aggressive multimodal treatment

BACKGROUND

Mucormycosis is an invasive mycotic disease caused by fungi in the zygomycetes class. Although ubiquitous in the environment, zygomycetes are rarely known to cause invasive disease in immunocompromised hosts with a high mortality even under aggressive antifungal and surgical therapy. Clinically, mucormycosis frequently affects the sinus occasionally showing pulmonary or cerebral involvement. However skeletal manifestation with Rhizopus microsporus (RM) osteomyelitis leading to emergency surgical proximal femoral resection with fatal outcome has not been described yet.

CASE PRESENTATION

We report the case of a 73-year-old male suffering from myelodysplastic syndrome with precedent bone marrow transplantation. Six months after transplantation he consulted our internal medicine department in a septic condition with a four week history of painful swelling of the right hip. Radiography, computed tomography and magnetic resonance imaging revealed multiple bone infarcts in both femurs. In the right femoral head, neck and trochanteric region a recent infarct showed massive secondary osteomyelitis, breaking through the medial cortex. Emergency surgical proximal femoral resection was performed due to extensive bone and soft tissue destruction. Microbiological and basic local alignment search tool (BLAST) analysis revealed RM. Amphotericin B and posaconazole treatment with septic revision surgery was performed. However the disease ran a rapid course and was fatal two months after hospital admission.

CONCLUSION

This alarming result with extensive RM osteomyelitis in the proximal femur of an immunocompromised patient may hopefully warn medical staff to perform early imaging and aggressive surgical supported multimodal treatment in similar cases.

Pathogenesis and host defence against Mucorales: the role of cytokines and interaction with antifungal drugs

Innate immune response, including macrophages, neutrophils and dendritic cells and their respective receptors, plays an important role in host defences against Mucorales with differential activity against specific fungal species, while adaptive immunity is not the first line of defence. A number of endogenous and exogenous factors, such as cytokines and growth factors as well as certain antifungal agents have been found that they influence innate immune response to these organisms. Used alone or especially in combination have been shown to exert antifungal effects against Mucorales species. These findings suggest novel ways of adjunctive therapy for patients with invasive mucormycosis.

[Disseminated mucormycosis in immunocompetent patients: A disease that also exists]

Mucormycosis is usually an acute angioinvasive infections, which leads to non-suppurative necrosis and significant tissue damage. It represents 1.6% of all the invasive fungal infections and predominates in immunosuppressed patients with risk factors. Incidence has been significantly increased even in immunocompetent patients. Due to finding a case of disseminated mucormycosis caused by Rhizomucor pusillus in a young immunocompetent patient, a systematic review was carried out of reported cases in PubMed of mucormycosis in immunocompetent adults according to the main anatomic locations, and especially in disseminated cases. A review of the main risk factors and pathogenicity, clinical manifestations, techniques of early diagnosis, current treatment options, and prognosis is presented. Taxonomy and classification of the genus Mucor has also been reviewed.

Clinical features and outcome of mucormycosis

Mucormycosis (MCM) is a life-threatening infection that carries high mortality rates despite recent advances in its diagnosis and treatment. The objective was to report 14 cases of mucormycosis infection and review the relevant literature. We retrospectively analyzed the demographic and clinical data of 14 consecutive patients that presented with MCM in a tertiary-care teaching hospital in northern Mexico. The mean age of the patients was 39.9 (range 5-65). Nine of the patients were male. Ten patients had diabetes mellitus as the underlying disease, and 6 patients had a hematological malignancy (acute leukemia). Of the diabetic patients, 3 had chronic renal failure and 4 presented with diabetic ketoacidosis. All patients had rhinocerebral involvement. In-hospital mortality was 50%. All patients received medical therapy with polyene antifungals and 11 patients underwent surgical therapy. Survivors were significantly younger and less likely to have diabetes than nonsurvivors, and had higher levels of serum albumin on admission. The clinical outcome of patients with MCM is poor. Uncontrolled diabetes and age are negative prognostic factors.

Disseminated mucormycosis in a paediatric patient: Lichthemia corymbifera successfully treated with combination antifungal therapy

Mucormycosis is a severe fungal infection that largely affects immunocompromised individuals. It carries a high morbidity and mortality rate and is characterised by extensive angioinvasion and necrosis of host tissue. This case report details success in treating disseminated mucormycosis in a paediatric patient with an underlying haematological malignancy. Treatment included institution of combination antifungal therapy with liposomal amphotericin B and caspofungin, aggressive surgical debridement of infected tissue and reversal of underlying immunosuppression.

Looks like a stroke, acts like a stroke, but it's more than a stroke: a case of cerebral mucormycosis

Mucormycosis is a fungus that exhibits angiocentric growth and can cause a thrombotic arteritis. Infection with this organism is uncommon and cerebral involvement is most often secondary to direct invasion through the paranasal sinuses. Here, we present a case of mucormycosis with cerebral involvement without sinus disease, which resulted in ischemic stroke with rapid progression resulting in death.

A long-term survivor of disseminated Aspergillus and mucorales infection: an instructive case

Invasive fungal infections remain major causes of infection-related mortality in hematopoietic stem cell transplantation (HSCT) patients. Mixed infections and multiple organ involvement have been reported in these patients. Here, we report a case of mixed Aspergillus and Mucorales infection involving the lungs, brain, spleen and bone in a HSCT patient with relapsed acute myeloid leukemia, who finally improved with triple antifungal therapy and neurosurgical evacuation of brain abscesses. She was put on lifelong secondary prophylaxis with posaconazole with excellent compliance and no sign of toxicity despite over 10 years of drug administration. Serial galactomannan measurements and positron emission tomography/computed tomography were used and were helpful for disease activity monitoring. This is an instructive case of long-term survival after a severe combined mould infection.

Mucormycosis in patients with inflammatory bowel disease: case series and review of the literature

Mucormycosis is a rare and often fatal invasive fungal infection mostly seen in immune-compromised individuals. A high index of clinical suspicion is necessary, so that effective preemptive therapy can be started, as timely intervention is crucial. In this series we present three cases of invasive mucormycosis in patients with underlying inflammatory bowel disease that had received therapy with immunomodulators prior to the infection. All three had varied clinical manifestations. We also review the literature of invasive mucormycosis in patients with inflammatory bowel disease.

Solitary pulmonary nodule: A rare presentation of pulmonary mucormycosis in an immunocompetent adult

Pulmonary mucormycosis is a rare opportunistic infection of immunocompromised individuals. Here, we report a case of 70-year-old male, smoker presenting with high-grade fever for 2 weeks and episodes of hemoptysis. Contrast-enhanced computed tomography (CT) thorax revealed a solitary pulmonary nodule measuring 2.3 × 1.6 cm in the right upper lobe. CT guided fine needle aspiration cytology and true cut biopsy showed plenty of typical fungal hyphae consistent with the diagnosis of mucormycosis. Fungal culture confirmed the organism as mucor. Positron emission tomography-CT scan showed a non- 18 fluorodeoxy glucose avid nodule ruling out possibility of malignancy. Investigation did not reveal any evidence of immunosuppression. Patient was treated with intravenous liposomal amphotericin B for 4 weeks. Follow-up chest X-ray and CT scan after 6 weeks were normal.

Necrosis of maxilla, nasal, and frontal bone secondary to extensive rhino-cerebral mucormycosis

Mucormycosis is an opportunistic fulminant fungal infection caused by zygomycetes. This fungus can cause a variety of infections in human beings, particularly in the uncontrolled diabetes mellitus. Zygomycetes impinge into the vascular network, resulting in thrombosis and necrosis of the surrounding hard and soft tissues. The infection begins in the nose and paranasal sinuses due to inhalation of fungal spores and spread to orbital and intracranial structures either by direct invasion or through the blood vessels. Sinus mucormycosis is often accompanied by a poor prognosis and a high mortality rate. Hence, aggressive surgical intervention with antifungal therapy is usually necessary. Early diagnosis and prompt treatment can reduce the mortality and morbidity of this lethal fungal infection. We report a case of aggressive rhino-cerebral mucormycosis in a 58-year-old female patient with uncontrolled diabetes mellitus.